Antimuscarinic drug therapy for overactive bladder syndrome in the elderly – are the concerns justified?

ABSTRACT

Introduction: The use of antimuscarinic drugs is common in the management of the overactive bladder (OAB). Concerns have been raised over their use in the elderly population in whom the use of these drugs is highly prevalent, consequent to the reported link between these drugs and cognitive impairment and dementia.

Areas covered: Recent publications have heightened concerns regarding antimuscarinic drug use in the elderly. In this review, the author discusses the available evidence upon which conclusions have been based and has presented the need for cortical review and need for caution in interpreting the data. The available evidence is inconsistent, differences in pharmacokinetics have not been widely recognized in clinical trials, clinical estimation of antimuscarinic activity has not been standardized, and serum antimuscarinic activity has not been found to correlate with cognitive impairment. Furthermore, the significant heterogeneity within cognitive aging processes raises questions regarding the extent to which various factors, including medication, influences this process.

Expert opinion: Whilst caution should indeed be exercised in the use of antimuscarinic medication in the elderly, advocacy of discontinuation of their use may deprive patients of the benefits of improved quality of life from treatment where currently alternative management remain limited or invasive.

KEYWORDS:

• Anticholinergic drugs
• Antimuscarinic drugs
• overactive bladder
• incontinence
• ageing
• cognition

Article highlights box

• Specific individual factors such as an understanding of the functional impairments that may have a negative effect on continence and need to be fully recognized when prescribing for overactive bladder/UI in the elderly as part of the Comprehensive Geriatric Assessment.

• Overactive bladder and other lower urinary tract dysfunctions may be integral to various central nervous system dysfunctions in the elderly including dementia, stroke, and Parkinson’s disease.

• It is essential that health-care providers fully understand the additive effects of anticholinergic drugs and their potential for harm with respect to cognitive function, dementia and other ‘class effects’ in the elderly population.

• There is a lack of longitudinal studies that provide meaningful information on the effects of long-term anticholinergic drug use on cognitive function and increased risk of incident dementia and those that do exist have methodological shortcomings or limited data.

• Anticholinergic scales are a clear, simple and clinically effective means for assessing and/or reducing the risk of anticholinergic drugs as well as raising awareness of polypharmacy to prescribers. They do, however, have significant limitations.

• The benefits of the use of anticholinergic medications should not be underestimated and health-care professionals should not be deterred from prescribing them as long as it is done carefully and appropriately.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript is not funded.