Medications For Incontinence Bad For Your Brain?

Recent research from the University of Washington suggests that long-term use of anticholinergic medications increases the risk of dementia (Gray SL et. al. JAMA 2015).

Anticholinergics block the action of acetylcholine, a common neurotransmitter.  The receptors for acetylcholine are found in all parts of the body; many drugs take advantage of anticholinergic effects to provide relief of symptoms (as in overactive bladder) but anticholinergic actions are commonly the cause of drug side effects (dry mouth, constipation).

While it has long been appreciated that some anticholinergics can cause central nervous system side effects (confusion, sedation, etc.) this seemed to affect primarily the frail elderly and at higher doses.  Drug companies have marketed certain products as being “safer” because they are less likely to cross the blood-brain barrier or less likely to interact with the specific receptors found in the brain. 

These investigators in this study followed over 3400 older adults (over age 65) in the Pacific Northwest for up to 10 years.  They identified nearly 800 new cases of dementia during the observation period.   When they examined medication use and development of dementia they found that the risk of dementia increased with the cumulative anticholinergic exposure (dose x years of use).  For those with the very highest exposure the increased risk was approximately 50%. 

Anticholinergics are used very commonly in urology and are some of the most effective drugs for overactive bladder and interstitial cystitis.  So what is the “take-home” message?  We have always believed that drug therapy should be a bridge to restoring normal urinary tract function.  Effective pharmacologic therapy should always be combined with behavioral therapy and pelvic floor rehabilitation.  When patients achieve a true complete remission and have regained normal function we find that the drugs can generally be slowly titrated off.  When this approach is not successful other treatment options should be considered (bladder instillations, neuromodulation, Botox injections, surgery) rather than a lifetime commitment to drug therapy.