Drugs and Alzheimers

Alzheimer’s, dementia, common medications increase risk

 SUMMARY:  Alzheimer’s, dementia, common medications increase risk; many medications have anticholinergic effects.  Three most commonly used in elderly were associated with irreversible brain impact (dementia and Alzheimer’s) and despite knowledge of the need for reducing such use, 3/4 of the study cohort had been prescribed at least one (antihistamine, acid reducers, antidepressant…).

UPDATE:  This post addresses the adverse cognitive impact in the elderly of common drugs due to anticholinergic effects.  There is however another mechanism for dementia and Alzheimer’s.  The later post, HEARTBURN DRUGS, DEMENTIA, ALZHEIMER’S RISK FOR ALL? T2D, IS IT THE CANARY IN THE COAL MINE!?! addresses this other mechanism for dementia and Alzheimer’s  for common heartburn drugs (microbiome skew and B12 (and other) nutrient depletion) for proton pump inhibitors (PPIS) and Histamine H2 antagonists (H2RAs) .Last updated: January 10, 2017 at 21:47 pm 

The goal of diet and lifestyle modifications

Reducing and/or eliminating medications using diet and lifestyle changes that improves health and immunity often times resolves disease symptoms; this is one goal of my awareness efforts. The unknowns of long term medication exposure(s) has always concerned me as studies are sorely lacking.

Is it really possible that diet and lifestyle changes can allow one to move off mediation?  This UMass study showed success for 24 IBD patients eating a whole foods diet which follows the guidelines of a slightly modified SCD diet.  Conclusion:  “The SCD modified dietary protocol can be used as an adjunctive or alternative therapy for the treatment of IBD. Notably, 9 out of 11 patients were able to be managed without anti-TNF therapy, and 100% of the patients had their symptoms reduced.   When you can take someone who can not digest (these folks were seriously ill long term) and turn health around to the point of not needing TNF medications, I don’t know how much more evidence you need that such is possible.  See the post, FOOD MANAGING IBD & AUTISM: THE STUDIES, for more details of the diet UMass used with a focus on autism and IBD.

Commonly used medications are found to be associated wtih dementia and Alzheimer’s in the elderly

The study (just published Jan., 2015) Cumulative Use of Strong Anticholinergics and Incident Dementia exemplifies the long term medication exposure(s) concern as it is the first to show a dose response (for either higher doses or for a longer usage time) linking more risk for developing dementia, including Alzheimer’s disease, due to use of three common anticholinergic medications: tricyclic antidepressants, first-generation antihistamines, and bladder antimuscarinics“20 to 50% of those 65 years of age or older use at least one medication with some anticholinergic activities.3,58  –The cognitive impact of anticholinergics: A clinical review

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I want to stress that there is no evidence that anticholinergic drugs cause dementia, rather there is an association link.

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What are anticholinergic effects, and what are these common medications that have anticholinergic effects?

Anticholinergic effects happen because some medications block the neurotransmitter called acetylcholine in the brain and body. That can cause many side effects, including drowsiness, constipation, retaining urine, and dry mouth and eyes.  Older people are more likely to experience anticholinergic effects because the amount of acetylcholine in the body decreases with age or there may be an increase in acetylcholinesterase, the enzyme that breaks down acetylcholine.  Consequently, anticholinergic drugs block a higher percentage of acetylcholine so that the aging body is less able to use what little acetylcholine is present. Aging and Drugs, MERCK Home Manual.

The central nervous system of older patients is very sensitive to the above adverse anticholinergic effects due to the significant decrease in cholinergic neurons or receptors in the brain of older adults, the reduction in hepatic metabolism and renal excretion of medications, and the increase in blood–brain barrier permeability.9 –The cognitive impact of anticholinergics: A clinical review.

Franklin Institute, The Human Brain, provides:

Acetylcholine is the primary chemical carrier of thought and memory. This excitatory neurotransmitter is essential for both the storage and recall of memory, and partly responsible for concentration and focus. It also plays a significant role in muscular coordination . A deficit in acetylcholine is directly related to memory decline and reduced cognitive capacity.

Unlike other key neurotransmitters, acetylcholine is not made from amino acids. Its primary building block is choline, which doesn’t have to compete for entry into your brain. Therefore, the more choline you consume, the more acetylcholine you can produce. Choline belongs to the B family of vitamins and is a fat-like substance that’s necessary to metabolize fats. It is found in lecithin as phosphatidyl choline. Foods high in lecithin include egg yolks, wheat germ, soybeans, organ meats, and whole wheat products.

You can boost your acetylcholine levels by taking supplements of phosphatidyl choline, which is also the form of choline most important to the structure of your neural membranes. Vitamin C and B5 are needed for your brain to synthesize acetylcholine, in the presence of choline acetyltransferase, a key brain enzyme.

Acetylcholine levels tend to decline with age, in part because of a decreased ability to synthesize this enzyme. There also may be an increase in acetylcholinesterase, the enzyme that breaks down acetylcholine.

Details for Cumulative Use of Strong Anticholinergics and Incident Dementia:

The study looked at 3434 participants 65 years or older with no dementia at study entry.  The study considered the most common anticholinergic classes used which were: tricyclic antidepressants, first-generation antihistamines, and bladder antimuscarinics:

  • Tricyclic antidepressants like doxepin (Sinequan) 10 mg/day,
  • First-generation antihistamines like chlorpheniramine, 4 mg/day (this dose is in one Chlor-Trimeton Allergy Relief, 4 Hour Tablet), also diphenhydramine drugs such as Nytol, Benadryl, or
  • Antimuscarinics for bladder control like oxybutynin (Ditropan) 5 mg/day of oxybutynin.
  • Results of the study found that greater risk for developing dementia occurs for people taking these meds for at least three or more years.  In a mean followup of 7.3 years, 23.2% (797 people) developed dementia, of whom 79.9% ( 637) were thought to have Alzheimer’s disease.
  • Some participants will have their brains autopsied after death; this will provide insight into whether participants who took anticholinergic medications actually have more Alzheimer’s-related pathology in their brains compared to nonusers.
  • Additionally, the risk for dementia was similar when comparing adults with recent and past heavy use with nonusers, suggesting that the risk for dementia with anticholinergic use may persist despite discontinuation of therapy, and may not be reversible even years after people stop taking these drugs.

This ScienceDaily article also discusses the study:  Higher dementia risk linked to more use of common drugs.

What drugs are anticholinergic drugs?  A lot, and even your child likely took a few.

Nearly a fifth of the anticholinergic medications in the study had been bought over the counter. The below images show  Anticholinergic Medications commonly used in Older Adults:

  1. Anticholinergic Pocket Reference Card, The University of Iowa, Health Effectiveness Research Center
  2. Iowa Center for Education and Research on Therapeutics The University of Iowa
  3. ABC Anticholinergic Burden Scale, Aging Brain Care (just sign in and download for free the various PDFs.)

These meds include sleep remedies, antihistamines, and medications for cough and cold, muscle spasms & pain, asthma, C.O.P.D., stomach and GI tract.

Honestly, what caught my eye in the study was the  first-generation antihistamines association and that acid reflux meds like Zantac and tagamet, and even eye drops, are anticholinergic.  
Antihistamines are used for allergies such as hay-fever or to aid sleep/promote drowsiness.

Such includes diphenhydramine drugs since they have anticholinergic effects; they block the action of acetylcholine and are used as a sedative because they cause drowsiness (see MedicineNet.com, diphenhydramine, Benadryl.) 

Lots of children use allergy diphenhydramine meds and despite youth supposedly having a lot of acetylcholine and decrease in acetylcholinesterase, the enzyme that breaks down acetylcholine, children still experience anticholinergic effects, especially the drowsy effect.  Still unknown would be:

  1. The brain impact on long term use (what ever that quantifiable might be) for the yet developing brain and
  2. Reversibility if brain impact occurs; it is not reversible for the aged given the findings from Cumulative Use of Strong Anticholinergics and Incident Dementia.

Diphenhydramine drugs having anticholinergic effects from MedlinePlus are:

Diphenhydramine drugs_nlm.hih.gov
Source: Diphenhydramine, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682539.html
Acid reflux medications next caught my attention.

Those having anticholinergic effects include cimetidine (Tagamet) and ranitidine (Zantac).  These medications are used by many long term and it seems at some point, acetylcholine levels would decrease with age making long term brain impact possible.  I will note here just for the record: clients using these meds have been able to wean off them with dietary changes that incorporate:

Additionally, there are even more considerations for other meds that are considered anticholinergic

Drugs to Avoid in Patients with Dementia, PHARMACIST’S LETTER / PRESCRIBER’S LETTER, lists in addition to known medications with strong anticholinergic side effects, those drugs not typically associated with major anticholinergic side effects (e.g., narcotics, benzodiazepines) that have anticholinergic like effects such as urinary retention and dry mouth; these cause acute confusional states.3  The report also lists factors that may determine whether a patient will develop cognitive impairment when exposed to anticholinergics which includes: 1) total anticholinergic load (determined by number of anticholinergic drugs and dose of agents utilized), 2) baseline cognitive function, and 3) individual patient pharmacodynamic and pharmacokinetic features (e.g., renal/hepatic function).1  See the report for meds listed if below is not clear, as well as cite references:

Most importantly, there are alternative non-anticholinergic medications and therapies

Second-generation antihistamines that are not anticholinergic  (see below slide from Drugs to Avoid in Patients with Dementia, PHARMACIST’S LETTER / PRESCRIBER’S LETTER) are loratadine (Claritin) and cetirizine (Zyrtec).   For depression, selective serotonin re-uptake inhibitors that are not anticholinergic are citalopram (Celexa) or fluoxitene (Prozac).  SSRIs are actually preferred over TCA due to TCA tolerance and safety issues — further discussion is below.  Also  note: diet and lifestyle modifications (exercise for one) can go far in managing depression.  Regarding the bladder medications, while it doesn’t seem like medication alternatives are available, non-drug behavioral therapy for urinary incontinence may be a viable alternative to this medication.

Other studies support this anticholinergic – dementia study
  1. In the population-based study of French adults aged 65 and older, Drugs with anticholinergic properties, cognitive decline, and dementia in an elderly general population: the 3-city study
    • 520 of the 6912 subjects (7.5%) were taking anticholinergic drugs at base-line, of whom 36 subjects (6.9%) were taking two anticholinergic drugs simultaneously, and eight (1.5%) three.
    • The main drug classes consisted of antidepressants (1.9%), digestive antispasmodics (1.6%), genital-urinary antispasmodics (1.3%), H1-anti-histaminics (1.0%), anxiolytics (0.9%), cardiovascular medications (0.5%), antiepileptics (0.5%), antipsychotics (0.3%), antiasthmatics (0.1%), and antiparkinson drugs (0.1%)
    • Finding: A significant association between anticholinergic use at base-line and the risk of developing dementia at 4-year follow-up.  Chronic anticholinergic users were at higher risk of incident dementia compared to non users, or persons having discontinued intake at the beginning of the follow-up. While this finding has not been previously reported, this agrees with the study by Perry et al. on autopsied Parkinson’s disease patients treated with anticholinergics; Alzheimer-type pathology being observed in patients who had been treated for more than two years compared to short-term anticholinergic treated or untreated cases.37
    • Discontinuing anticholinergic treatment was associated with a decreased risk.
    • Medical practitioners should monitor current anticholinergic drug use in elderly patients and seek pharmacological alternatives before considering administration of neuroprotective medications to persons with MCI, thus escalating a prescription cascade involving cholinesterase inhibitors and anticholinergic drugs.10, 41, 42 This is especially important considering that long-term concomitant therapy with anticholinergics may be associated with significant deleterious effects on acetylcholinesterase therapy, and may have adverse effects on the clinical course of Alzheimer’s disease.43,44
  2. Dr. Eric Larson, executive director of the Group Health Research Institute (who worked on the Cumulative Use of Strong Anticholinergics and Incident Dementia study, in an email to Reuters Health,) noted showing that the risk of a permanent progressive brain disease like Alzheimer’s was associated with these drugs was extremely surprising as the anticholinergic drugs were felt to only have effects that were time limited – no structural brain changes were felt to be a consequence. Because of the surprising nature of the findings, there was a lot of skepticism, especially since drugs with these features are very commonly used.  Thus, [the Cumulative Use of Strong Anticholinergics and Incident Dementiastudy published in JAMA Internal Medicine confirms the results and in a much more rigorous design and in a second population. The findings confirming the earlier study make this a much more convincing and concerning finding.”
  3. The German study, Anticholinergic drug use and risk for dementia: target for dementia prevention, found for adults aged 75 or older, that any anticholinergic drug use over 4.5 years was associated with a greater than twofold increased risk of dementia compared with no use (adjusted HR 2.08).
Despite knowledge to minimize elderly exposure to these medications, 3/4 of the study cohort in the Cumulative Use of Strong Anticholinergics and Incident Dementia had been exposed to at least one strong anticholinergic in the 10 year study period.

While it makes clinical sense to minimize exposure to these medications among older adults,  the contrary exposure occurred despite the American Geriatrics Society recognition that anticholinergics, benzodiazepines, and histamine H2 receptor antagonists are potentially inappropriate for older adults owing to their adverse cognitive effects. Adverse Cognitive Effects of Medications Turning Attention to Reversibility   

Histamine H2 receptor antagonists & benzodiazepines have adverse cognitive effects. Still more drugs with cognitive effects..  What are histamine H2 antagonist meds?

That certainly opens a can of worms.  While this post is primarily limited to discussing anticholinergic antihistamines and brain impact, the above comment adds histamine H2 receptor antagonists and benzodiazepines into the mix of drugs having adverse cognitive effects.   Benzodiazepines (prescribed for anxiety and sleep) are discussed below.  But note the large amount of drugs that Mayo Clinic lists as histamine H2 antagonists in: Histamine H2 Antagonist (Oral Route, Injection Route, Intravenous Route, which further explains: these medications are also known as H2-blockers.  They are used to treat gastric and duodenal ulcers and prevent their return. In over-the-counter (OTC) strengths, these medicines are used to relieve and/or prevent heartburn, acid indigestion, and sour stomach.  Many people are on these long term.  I do not know what the “cognitive impact” is due to these; you’ll need to do your own research if you are interested.

  1. Axid
  2. Axid AR
  3. Axid Pulvules
  4. Heartburn Relief
  5. Pepcid
  6. Pepcid AC
  7. Tagamet
  8. Tagamet HB
  9. Zantac
  10. Zantac 150
  11. Zantac 150 Efferdose
  12. Zantac 25
Conclusions and Relevance from the study, Cumulative Use of Strong Anticholinergics and Incident Dementia:
  • Higher cumulative anticholinergic use is associated with an increased risk for dementia.
  • Efforts to increase awareness among health care professionals and older adults about this potential medication-related risk are important to minimize anticholinergic use over time.
  • Taking just two drugs with anticholinergic effects, such as some drugs for heart disease, antihistamines, antidepressants, antipsychotics, and even warfarin, can treble the risk of death in the over 65s. Doctors have been advised to assess the combined anticholinergic burden of all drugs that a patient is taking—prescribed drugs and those bought over the counter—before prescribing any additional ones. GPs have also been reminded of the importance of regularly reviewing patients’ drugs.Anticholinergic effects of common drugs are associated with increased mortality in over 65s.  
  • Alternate meds should be tried first and if anticholinergic are used, the meds should at lowest effective dose and stopped if found to be ineffective.
Some details on the Tricyclic antidepressants:

Many guidelines recommend SSRIs rather than TCAs because of safety.  Both are effective, and if safety is not an issue, then individual tolerability to side effects will determine types of medications used. Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis and Review: selective serotonin reuptake inhibitors are as effective as tricyclic antidepressants overall but may be less effective in some patient subgroups.

Cyclic antidepressants are designated as tricyclic or tetracyclic, depending on the number of rings in their chemical structure — three (tri) or four (tetra). Tricyclic antidepressants approved by the FDA to treat depression, Tricyclic antidepressants and tetracyclic antidepressants, Mayo Clinic, are:

  • Amitriptyline
  • Amoxapine
  • Desipramine (Norpramin)
  • Doxepin
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
  • Protriptyline (Vivactil)
  • Trimipramine (Surmontil)

Antidepressants alter the balance of some chemicals in the brain called neurotransmitters.  Neurotransmitter imbalance is thought to play a part in causing depression and other conditions. Cyclic antidepressants block the absorption of the neurotransmitters serotonin and norepinephrine, making more of these chemicals available in the brain. This seems to help brain cells send and receive messages, which in turn boosts mood. Most antidepressants work by changing the levels of one or more neurotransmitters.  Cyclic antidepressants also affect other chemical messengers, which can lead to a number of side effects.

Some details on the benzodiazepines (prescribed for anxiety and sleep):

The Daily Mail article asks, Do sleeping pills give you Alzheimer’s? As a major new study suggests a link, we examine the worrying evidence:

  • French and Canadian study:  people who take benzodiazepines — drugs commonly prescribed for anxiety and sleep problems — have a significantly higher risk of developing Alzheimer’s. This has shocking implications — at any one time, an estimated 1.5 million people in the UK, mainly the over-65s, are taking benzodiazepines.
  • The drugs include diazepam (previously known as Valium), lorazepam, temazepam and nitrazepam.  Under guidelines from the UK’s Safety of Medicines Committee, the drugs should be prescribed for only 2 to 4 weeks because of the risk of addiction though patients may inadvertently be on them long term.  Newer drugs —which include zopiclone, zaleplon and zolpidem are prescribed since they were thought to not be addictive, but they in fact are addictive.  Their link to Alzheimer’s is not studied yet.  There’s a whole generation of people now hitting old age who were put on drugs such as Valium and temazepam years ago and I’d argue we’re now beginning to see the long-term impact of those drugs on the brain,’
  • The new study, published in the British Medical Journal and which involved nearly 9,000 people aged 66 and older, including 1,796 with Alzheimer’s, found that patients prescribed the drugs for any length of time — even just a few weeks — were 51 per cent more likely to get Alzheimer’s, compared with someone who’d never taken them.
  • The risks went up the longer patients were on the drugs.  Those taking them for three to six months were 32 per cent more likely to develop Alzheimer’s with the figure rising to 84 per cent if they took the pills for more than six months.

See also the Daily Mail article, Prescription sleeping pills taken by more than one million Britons ‘can raise chance of developing Alzheimer’s by 50%.

As always, scrutinize the need for medication and research side effects.  It is through increased awareness comes health,

Last updated: January 10, 2017 at 21:47 pm  to correct the broken link for: ABC Anticholinergic Burden Scale, Aging Brain Care.

Prior update March 22, 2016 added link to another mechanism of cognitive impairment which is heartburn drugs PPI and H2RA, HEARTBURN DRUGS, DEMENTIA, ALZHEIMER’S RISK FOR ALL? T2D, IS IT THE CANARY IN THE COAL MINE!?!

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5 thoughts on “Alzheimer’s, dementia, common medications increase risk”

  1. One perspective from Australia – I have regular contact with my 93 yo mother in law who is in care and has been for approximately 10 years.
    Our approach to care with our elderly is based on medicine with a high degree of pharmaceutical administration and treatment. Food is your medicine, sure, but for our elderly my observations are that of a diet of high sugar, processed foods with processed carbohydrates. And I cannot stand the smell of this food at the dinner table. Dementia and associated conditions is rife with more medication administered, a vicious nasty cycle until death. Gastro and associated GIT disorders is not uncommon. ABX is freely administered as our medics know, no different. Microbiome is only a word in the dictionary when associated with this old age care centre. Its a sad world in this respect, particularly when so many of these aged inmates stagger around, medicated and with minimal quality of life. But, statistically, these people are staying alive longer and more in firmed due to pharmacology. Lucky my direct family are mostly lchf, paleo with probiotics and whole foods daily.

    1. Thank you for your insights. So many should feel so duped by pharma. The systemic effects to organs beyond that targeted is concerning; losing cognition permanently is an eye opener. In the UK, the US Beers tool (used to assess elderly drug risk) cannot be used since approximately fifty percent, that is no typo… approximately 50% of the Beers drugs are unavailable in European countries. -See “Potentially inappropriate prescribing among older people in the United Kingdom,” http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-72#CR8 , reference 8 therein.

      LCHF… the type of fat matters. Good of you to nix the Omega-6 seed oils. Furthermore, understand that there is real issue for many consuming animal protein because their unique microbiome produces harmful metabolites, TMAO being one. The why’s and how’s is complex. Dr. Mark Hyman (Cleveland Clinic Functional Medicine fame) held a Fat Summit. Hyman’s interviews pushed the meat/microbiome researchers themselves diving not just into their findings but also diving into their take for the conflicting research findings (there are many beyond just the quality CAFO/grass-fed type questions). Does changing the Standard American Diet crummy depleted less diverse microbiome through diet make consumption of animal protein safer? While it no doubt improves one’s health, the jury is still out if it pushes the microbiome enough so that microbiome metabolites from animal proteins are not harmful; studies are sorely lacking. Thus Hyman’s condimeat suggestion; after-all, there are more less controversial healthy fat choices.

      LCHF… the types of carbs is controversial… Non-starchy crunchy vegetables like asparagus, broccoli, green beans, cabbages, beets are no brainers… they clearly benefit by not raising blood sugar and the microbiome benefits too. Eating lots of colors helps to heal giving plenty of phytonutrients. Beans and grains… you know their gut risks and they raise blood sugar consumed in large amounts; many of those with autoimmunes and chronic disease don’t tolerate these well. The FODMAPs… how badly do we need to push to tolerate such for our microbiome health… how much, how much variety, and how often… incredibly tough questions for those healing the gut and finding such are not well tolerated. UMass IBD-AID diet gives a glimpse of the more easily tolerated high starch FODMAPs for those with very damaged guts (IBD)… sweet potatoes, well-cooked gluten-free oatmeal (actually twice the package instructions), properly prepared well cooked beans and lentils or purees at start… and I’ll add in here flax/chia ground seeds since they are missing from SCD/GAPS. Digestive enzymes may be a part of UMass IBD-AID. Quinoa (properly prepared/soaked/rinsed…) is not a part of the diet at this time only because they have not yet evaluated it. Seems fair to say your microbiome dictates what you can consume carb type wise and such changes the more one heals.

      Seems LCHF works incredibly well for healing or managing hormonal/neuro/metabolic conditions. Questions surrounding that is how far to move macronutrients (especially the carb types and loads that benefit the microbiome) with healing relative to long term diet.

      I suppose for the long term diet target, I agree (with some clarification) to Dr. Hyman’s conclusions that at this time, understanding where the science is, the best long term diet is what he named PEGAN diet, a cross between PALEO and vegan. He defines PEGAN as mostly low starch carbs, proteins from nuts, seeds, whole quality eggs, small amounts of beans and grains (primarily because large amounts raises blood sugar) and condimeat quantity of grass-fed meats (the saturated fat profile may potentially be beneficial), and healthy fats: think Omega-3, avocados, nuts (walnuts macadamia, almonds, pecans), seeds (hemp, flax, chia, pumpkin), olive oil, coconut oil, and whole quality eggs. This definition is a bit deceptive however as I am aware of his admittance to supplementing resistant starch (potato starch) and ferments personally which he does not address in the overall context of PEGAN. So for PEGAN, add in ferments and some FODMAPs, and I’d think real food is the way to go for those. Email me if you want a copy of my pdf summary of Dr. Hyman’s Q&A Video on Fat published for his upcoming book, “Eat Fat, Get Thin”.

  2. Potentially inappropriate prescribing among older people in the United Kingdom, http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-72#CR8

    How do other countries assess elderly drug risk? They don’t use US Beers tool since approximately 50% of the Beers drugs are unavailable in European countries [8]. That is rather amazing!

    “Appropriateness of prescribing in older people has been most extensively assessed by process measures (provider’s actions) [2]. Explicit process measures are criterion-based and indicate drugs to be avoided in older people, independent of diagnoses or in the presence of certain diagnoses [3–5]. Explicit measures, requiring little clinical detail, can often be applied to large prescribing databases [2].”

    “The United States (US) Beers criteria, the most commonly used explicit process measure for assessing potentially inappropriate prescribing (PIP) in older people, has been widely validated [6, 7], but has some limitations; for example, approximately 50% of the Beers drugs are unavailable in European countries [8]. The recently developed ‘Screening Tool of Older Persons potentially inappropriate Prescriptions’ (STOPP) provides a more comprehensive explicit process measure of PIP, is validated for use in European countries [9], and overcomes some of the limitations inherent in the Beers criteria. STOPP is a physiological system-based screening tool comprising 65 clinically significant criteria which take drug-drug and drug-disease interactions, drug doses and duration of treatment into consideration. It considers clinical effectiveness and the removal of any potentially unnecessary drugs as well as drug duplication.”

  3. Guideline Title: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.

    An Update on the Beers’ Criteria: The Time is Here for Translation into Practice
    Table 2. 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf and paper link is: https://www.guideline.gov/content.aspx?id=37706

    Organ System/Therapeutic Category/Drug(s) lists under Central Nervous System, for Dementia and cognitive impairment, these drugs:

    Anticholinergics (see Table 9 for full list)
    Benzodiazepines
    H2-receptor antagonists
    Zolpidem
    Antipsychotics, chronic
    and as-needed use

    The rationale is:
    Avoid due to adverse CNS effects.
    Avoid antipsychotics for behavioral problems of dementia unless
    nonpharmacologic options have failed and patient is a threat to themselves or others.
    Antipsychotics are associated increased risk of cerebrovascular
    accident (stroke) and mortality in persons with dementia.

    Recommendation: avoid
    Quality of evidence: high
    Strength of recommendation: strong

    Referneces (see pdf link for direct links to the below references):
    Boustani 2007
    Hanlon2004
    Finkle 2011
    Frey 2011
    Paterniti 2002
    Rasmussen 1999
    Rudolph 2008
    Schneider 2005
    Schneider 2006a
    Schneider 2006b
    Seitz 2011
    Vigen 2011
    Wright 2009

Now I'd like to hear your thoughts... comments are always welcome!