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Anticholinergic Alert: Why Common Medications Can Worsen Dementia & What to Do

More than one in four older adults with dementia use a potentially inappropriate anticholinergic medication, often without realizing it. These drugs block acetylcholine, a brain chemical critical for memory and thinking, and can accelerate cognitive decline, increase confusion, and raise fall risk. The good news: many of these medications can be safely deprescribed or swapped for safer alternatives. This article walks you through the factors that increase the odds of inappropriate use, how to spot problem meds, and concrete steps to protect your loved one.

Key points

  • More than 1 in 4 older adults with dementia use a potentially inappropriate anticholinergic medication—check your loved one's list today.
  • Anticholinergic drugs block acetylcholine, worsening memory, confusion, and fall risk. They are found in bladder meds, antihistamines, some antidepressants, and sleep aids.
  • Polypharmacy (5+ meds) and multimorbidity are the strongest predictors of inappropriate use. Regular medication reviews are essential.
  • Use the Anticholinergic Burden Scale (acbcalc.com) to score every medication. A total score of 3+ is high risk.
  • Non-drug alternatives exist for many conditions: timed toileting for bladder, loratadine for allergies, melatonin for sleep.
  • Never stop a medication abruptly—always work with the prescriber to taper. Advocate for deprescribing at every visit.

What Are Anticholinergic Medications and Why Are They Risky?

Anticholinergic medications work by blocking the action of acetylcholine, a neurotransmitter that helps nerve cells communicate. Acetylcholine is essential for memory, attention, and muscle control. In dementia, the brain already has low levels of acetylcholine, so adding a drug that blocks it further can worsen confusion, cause delirium, and speed up cognitive decline. Research shows that the longer a person takes these medications, the higher their risk of developing dementia in the first place, and for those already diagnosed, the risk of further cognitive harm is significant.

These drugs are found in many common prescriptions and over-the-counter products. They include medications for bladder control (like oxybutynin), antihistamines (like diphenhydramine, found in Benadryl), some antidepressants (like paroxetine, brand name Paxil), and certain sleep aids. The problem is compounded when a person is on multiple anticholinergic drugs at once, a situation called high anticholinergic burden. This is especially dangerous for older adults with dementia because they are more vulnerable to drug side effects due to age-related changes in metabolism and kidney function.

What Factors Increase the Odds of Potentially Inappropriate Use?

Several factors make it more likely that an older adult with dementia will be prescribed or continue using an inappropriate anticholinergic. The strongest predictor is polypharmacy—taking five or more medications. The more drugs a person takes, the higher the chance that at least one will be anticholinergic. Multimorbidity (having multiple chronic conditions) also drives this, as conditions like urinary incontinence, allergies, depression, and insomnia are often treated with anticholinergic drugs. Living in the community (rather than a nursing home) may paradoxically increase risk because community-dwelling older adults often see multiple prescribers who may not coordinate care. Additionally, lack of regular medication reviews by a pharmacist or geriatrician means these drugs can stay on the list for years without being questioned.

Another major factor is that many anticholinergic drugs are available over the counter, so caregivers may not think to mention them to the doctor. For example, a caregiver might give their loved one Benadryl for a cold or sleep, not realizing it can cause confusion and falls. The Beers Criteria, a widely used list of potentially inappropriate medications for older adults, specifically flags diphenhydramine and other anticholinergics. Yet, because these drugs are so common, they are often overlooked. The bottom line: if your loved one is taking any medication for bladder control, allergies, sleep, or depression, it is worth asking whether it is anticholinergic and if a safer alternative exists.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Gather a complete medication list (prescriptions, OTC, supplements, as-needed), noting name, dose, frequency, and purpose—include items from the medicine cabinet, not just the pill organizer.

  2. Score each medication using the Anticholinergic Burden Scale at acbcalc.com (0–3) and flag any scoring ≥2, especially oxybutynin, tolterodine, diphenhydramine, paroxetine, or amitriptyline.

  3. Ask the pharmacist to run a drug-interaction check for anticholinergics that may counteract dementia medications like donepezil or rivastigmine.

  4. Present the list, ACB scores, and interaction report to the primary care doctor or geriatrician, asking to taper each high-risk drug gradually and swap to lower-burden alternatives (e.g., timed toileting or mirabegron for bladder; loratadine or cetirizine for allergies; low-dose melatonin for sleep; sertraline or citalopram for depression).

  5. After any change, monitor for 2–4 weeks, logging changes in clarity, falls, sleepiness, agitation, or memory to share at follow-up.

  6. Use a single pharmacy for all medications and ask the pharmacist to flag new anticholinergic prescriptions; bring the updated list to every doctor visit.

  7. If in assisted living or a nursing home, request a quarterly medication review by the facility’s consultant pharmacist, as federally required, and review results for anticholinergic use.

What not to do

  • Do not abruptly stop anticholinergic medications without prescriber guidance; some require gradual tapering to avoid withdrawal.

  • Do not assume OTC means safe; diphenhydramine (in Benadryl, Tylenol PM, Advil PM) commonly causes confusion and falls.

  • Do not accept 'we've always used this' as justification; dementia changes drug response, so request a deprescribing trial.

  • Do not rely solely on the primary care doctor to identify anticholinergic burden—use the ACB calculator yourself and bring results.

Practical tools

  • Anticholinergic Burden Scale (ACB) Calculator

    Free tool at acbcalc.com; enter medications to get scores (0–3); print results for the doctor.

  • Medication List Template

    Table with columns for Drug Name, Dose, Frequency, Prescriber, Reason, and ACB Score; update with each change; keep a copy on your phone for appointments.

  • Pharmacist Consultation Request

    Request a drug-interaction check focusing on anticholinergic burden and conflicts with dementia drugs; ask for a printout and, if high burden is found, ask the pharmacist to call the prescriber.

  • Deprescribing.org Patient Guides

    Free, evidence-based one-page guides for specific drug classes (bladder meds, antihistamines, antidepressants); print the relevant guide to support a tapering plan.

Discuss with your clinician

Ask the doctor: 'Is my loved one at high risk for anticholinergic side effects given their dementia? Can we calculate their anticholinergic burden?'

Ask: 'For any high-burden medication, what is the safest way to taper or stop it? Should we reduce the dose slowly over weeks?'

Ask: 'Are there any drug interactions between the anticholinergic and my loved one's dementia medication (donepezil, rivastigmine, memantine)?'

Ask: 'If we need to treat anxiety or depression, which antidepressants have the lowest anticholinergic burden? Is sertraline or citalopram an option?'

Ask: 'For bladder control, is mirabegron (Myrbetriq) a safer alternative to oxybutynin? Does insurance cover it?'

Ask: 'Should I be concerned about any over-the-counter medications I might be giving? Can you give me a list of safe OTC options?'

Related guides

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