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Checking OTC Medications for Anticholinergic Risks

Many common over-the-counter medications contain anticholinergic ingredients that can worsen confusion, increase fall risk, and even mimic dementia progression. This article helps you identify these hidden risks, provides a step-by-step process to check your loved one's medicine cabinet, and offers practical tools to discuss safer alternatives with their healthcare team. You are not alone in this — small changes can make a big difference in your loved one's clarity and comfort.

Key points

  • Many OTC sleep aids, allergy pills, and 'PM' pain relievers contain anticholinergic ingredients that can worsen dementia symptoms.
  • More than 1 in 4 older adults with dementia use at least one potentially inappropriate anticholinergic medication — often without their doctor knowing.
  • Always bring the actual medication bottles to doctor appointments — do not rely on a written list.
  • Use an online anticholinergic burden calculator (acbcalc.com) to check any medication.
  • For sleep, try non-drug strategies first; for allergies, use non-sedating antihistamines; for pain, use acetaminophen.
  • Schedule an annual medication review with the doctor or pharmacist to review all medications, including OTC and supplements.

What Are Anticholinergic Medications and Why Are They Risky?

Anticholinergic drugs block a brain chemical called acetylcholine, which is essential for memory, learning, and muscle control. In people with dementia, their brains are already struggling with acetylcholine deficits, so adding an anticholinergic can dramatically worsen confusion, cause sedation, increase fall risk, and even make dementia appear to progress faster. Research shows that more than one in four older adults with dementia are using at least one potentially inappropriate anticholinergic medication — often without their doctor knowing (source: PubMed study). These drugs are found in many everyday OTC products: sleep aids, allergy pills, cold and flu formulas, and even some pain relievers labeled 'PM.' The danger is that caregivers may reach for these to help with sleep or allergies, unaware they could be making dementia symptoms worse.

Why This Happens: The Hidden Burden on the Brain

As we age, our bodies absorb and eliminate medications more slowly, leading to accumulation of drug levels in the blood. For someone with dementia, the brain is especially vulnerable. Even a single dose of a sedating antihistamine like diphenhydramine (Benadryl) can cause hours of increased confusion, drowsiness, and unsteadiness. Over time, regular use can build up a 'cognitive burden' that mimics dementia progression — meaning your loved one might seem worse than they actually are. This is why experts recommend an annual medication review that includes all OTC products and supplements (source: James L. West Center for Dementia Care). The good news: stopping these medications often leads to noticeable improvement in clarity and function within days to weeks.

The Link Between Anticholinergics and Dementia Risk

Long-term use of anticholinergic medications has been associated with a higher risk of developing dementia in the first place. While this does not prove cause and effect, the association is strong enough that many specialists now recommend avoiding these drugs in older adults whenever possible. For someone already living with dementia, the risk is even greater — these drugs can worsen cognitive decline and increase the likelihood of falls, hospitalizations, and behavioral issues. This is not about blaming caregivers; it is about empowering you with knowledge to ask the right questions.

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

Step-by-step

  1. 1. Gather ALL medications — including OTC, supplements, and prescriptions — and put them in a bag. Do not rely on a written list; bring the actual bottles to your loved one's next doctor appointment. This ensures the doctor can see the exact ingredients, dosages, and expiration dates (source: Dementia Careblazers).

  2. 2. Identify anticholinergic ingredients on OTC labels. Look for: diphenhydramine (Benadryl, Tylenol PM, Advil PM, NyQuil), chlorpheniramine (Chlor-Trimeton), doxylamine (Unisom), dimenhydrinate (Dramamine), and scopolamine (Transderm Scop). Also check for 'PM' versions of pain relievers — the 'PM' ingredient is almost always a sedating antihistamine (source: Better Health While Aging).

  3. 3. Use an online anticholinergic burden calculator (like acbcalc.com) to check each medication. Enter the drug name and dose to see its 'anticholinergic burden score.' A score of 1-3 indicates low to high risk; any score above 0 is worth discussing with the doctor (source: Better Health While Aging).

  4. 4. Call your loved one's primary care provider or pharmacist and say: 'I found [name of OTC medication] in the medicine cabinet. Can you tell me if this is safe for someone with dementia? Are there any safer alternatives?' Leave a message with the nurse if the doctor is unavailable (source: Dementia Careblazers).

  5. 5. For sleep problems, do NOT reach for an OTC sleep aid. Instead, try non-drug approaches: a consistent bedtime routine, reducing caffeine after noon, a warm bath before bed, and exposure to natural light during the day. If sleep issues persist, discuss with the doctor — they may recommend a low-dose melatonin or a non-anticholinergic prescription option (source: Better Health While Aging).

  6. 6. For allergies, ask the pharmacist about non-sedating antihistamines like loratadine (Claritin), cetirizine (Zyrtec), or fexofenadine (Allegra). These have much lower anticholinergic effects and are generally safer for people with dementia (source: Dementia Careblazers).

  7. 7. For pain, use acetaminophen (Tylenol) as the first-line OTC pain reliever. Avoid NSAIDs like ibuprofen (Advil, Motrin) and naproxen (Aleve) unless specifically recommended by a doctor, as they can cause kidney issues and interact with other medications (source: Better Health While Aging).

  8. 8. For incontinence, be aware that oxybutynin (Ditropan) is a strong anticholinergic that can worsen confusion and increase fall risk. Ask the doctor about alternatives like mirabegron (Myrbetriq) or behavioral strategies (scheduled toileting, pelvic floor exercises) (source: Pamela D Wilson).

  9. 9. Schedule an annual 'deep dive' medication review with the doctor or pharmacist. Bring all medications in the bag and ask: 'Is each of these still needed? Is this the safest option for dementia? Are there any interactions?' (source: James L. West Center for Dementia Care).

  10. 10. Keep a running list of all medications (including OTC and supplements) in a notebook or on your phone. Update it every time a medication is started, stopped, or changed. Share this list with every healthcare provider at every visit (source: Family Caregiver Alliance).

What not to do

  • Do NOT assume that because a medication is over-the-counter, it is automatically safe for someone with dementia. OTC drugs are tested on healthy adults, not on older adults with cognitive impairment. Always check with a doctor or pharmacist first (source: Dementia Careblazers).

  • Do NOT give a 'PM' version of pain relievers (like Tylenol PM or Advil PM) for sleep. The sedating ingredient (diphenhydramine) is strongly anticholinergic and can cause confusion, falls, and worsen dementia symptoms. Instead, address insomnia with non-drug strategies (source: Better Health While Aging).

  • Do NOT stop an OTC sleep aid abruptly without a plan. Insomnia often gets worse for a few days after stopping, which can be distressing. Work with the doctor to taper off or replace it with a safer option (source: Better Health While Aging).

  • Do NOT rely on a written list of medications — bring the actual bottles. Lists can be outdated or miss OTC products. The doctor needs to see the exact ingredients and dosages (source: Dementia Careblazers).

  • Do NOT assume that a medication prescribed years ago is still appropriate. Dementia medications (like Aricept, Exelon, Razadyne, Namenda) should be reviewed every 6 months to ensure they are still helping and not causing side effects (source: Family Caregiver Alliance).

  • Do NOT use anticholinergic medications for incontinence (like oxybutynin) without discussing with a specialist. There are newer, safer options that do not cross the blood-brain barrier as much (source: Pamela D Wilson).

Practical tools

  • The Medicine Cabinet Check

    Set aside 30 minutes to go through every bottle in the medicine cabinet. Look for these ingredients: diphenhydramine, chlorpheniramine, doxylamine, dimenhydrinate, scopolamine, oxybutynin. Write down the name, dose, and how often it is taken. Then call the doctor or pharmacist with this list.

  • Anticholinergic Burden Calculator (acbcalc.com)

    This free online tool lets you enter any medication (prescription or OTC) and instantly see its anticholinergic burden score. A score of 3 is high risk. Use it to prioritize which medications to discuss with the doctor.

  • The 'Brown Bag' Appointment

    Once a year, put ALL medications (prescription, OTC, supplements, vitamins) in a brown paper bag and bring them to the doctor. Ask: 'Is each of these still needed? Is there a safer alternative for dementia?' This is a standard recommendation from experts (source: Dementia Careblazers, Family Caregiver Alliance).

  • Non-Drug Sleep Toolkit

    Create a calming bedtime routine: same time each night, dim lights, no screens 1 hour before bed, a warm (not hot) bath, a light snack (like a banana or warm milk), and a white noise machine. If sleep does not improve in 2 weeks, discuss with the doctor.

  • The 'Ask Your Pharmacist' Script

    When at the pharmacy, say: 'My loved one has dementia. Is this OTC medication safe for them? Does it have anticholinergic effects? Is there a non-sedating alternative?' Pharmacists are trained to help with this.

  • Medication List Template

    Keep a simple notebook or use a free app like Medisafe. Write: medication name, dose, frequency, start date, doctor who prescribed it, and any side effects noticed. Update it every time a change is made.

Discuss with your clinician

Ask the doctor: 'Is it safe for my loved one to take [name of OTC medication] with their current dementia medications?'

If the person is taking an anticholinergic for incontinence, ask: 'Are there non-drug options or a safer medication like mirabegron?'

If the person is taking a benzodiazepine (like Xanax, Valium) or a sleep aid, ask: 'Can we try a non-medication approach first? What is the safest way to reduce or stop this?'

If the person has been on a dementia medication (like donepezil) for more than 6 months, ask: 'Is this still the right dose? Should we consider a different medication?'

If the person is experiencing new confusion or falls, ask: 'Could this be related to an anticholinergic medication they are taking?'

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