Well, hello everyone. I'm Dr Leslie Kernisan, board certified geriatrician and the founder of BetterHealthWhileAging. net.
In this video, I'm going to talk about one of the top things that I address in my practice to help my older patients live better, especially if they've had any concerns about memory loss or brain health. And that is the four types of brain slowing medication to avoid. If you've been worried about memory or brain health, this is something that is foundational in geriatrics, checking for what we call the beers criteria medications, which means medications that are known to be drugs that older adults should avoid or use with caution.
So this is a list. It's a pretty long list of medications that geriatricians have been maintaining for over 20 years. And so in the practice of geriatrics, we especially look for medications that might be affecting an older person's thinking.
And why is this? It's because thinking abilities are just so important in later life to help older adults maintain independence and quality of life. Also, the same medications that affect memory and thinking also tend to affect balance and worsen falls, and that's another issue that we're very concerned about in geriatrics.
And then these medications that slow down the brain and affect thinking are especially important to identify if you or if someone you care about has a diagnosis of something like mild cognitive impairment, Alzheimer's, or another form of dementia. Now, if you're not quite sure what it means to have mild cognitive impairment or how it gets diagnosed or how to know if it's mild cognitive impairment or Alzheimer's, I have a video that is just about that, and you can watch that. Next, let me now get back to the four types of medication that I look for because they are especially likely to affect memory and brain function in older adults.
So I'm gonna go through them. I think you should know about these and you should know to ask questions if your doctor is recommending these to you. So the first type is a class of medications that is called benzodiazepines, or we often say benzos for short.
Benzos are a type of sedative, tranquilizer, and commonly prescribed benzos include lorazepam, diazepam, temazepam, alprazolam, and clonazepam. And the brand names for these are Ativan, Valium, Restoril, Xanax, and Klonopin respectively. So benzos are most often prescribed either to help a person manage anxiety or for sleep.
In much older patients, such as the ones that I tend to see in person, they're also often prescribed to manage agitation or difficult behaviors in Alzheimer's disease or other forms of dementia. But it's important for you to know that they are not FDA approved for this indication. So what are the risks of benzos?
Well, it turns out that benzos work actually quite well in the short term for anxiety and insomnia. That's why they have been relatively popular with patients and with providers. They give people really pretty quickly that, ah, I feel more relaxed feeling, which can help with anxiety or can help people get to sleep.
Benzos actually work in the brain on the same receptors as do alcohol. The thing is, as people get older, the side effects of benzodiazepines become more and more significant. So first of all, benzos are slowing the brain.
They are also slowing the brain of people who are in their twenties and forties, but it's less important when people are younger, whereas when people are older, this brain slowing can cause a noticeable decline in memory function or in other thinking functions. Benzos are also habit forming, so people quite easily can become physically dependent on them, especially if they use them every day or quite often. And this is both a, there can be a psychological dependence, as in people feel like they can't handle the situation without the benzo, but there's also a very real physical dependence and adaptation to the medication.
So what this means is, first of all, some people do develop an addiction to benzodiazepines or start to use them in an unhealthy way, you know, basically a form of substance abuse. And we see this more often in people who have already tended to abuse other substances like alcohol or other kinds of prescription medications. So that can really be a concern if people are using benzos, but even if they don't get addicted in an unhealthy way, the body becomes dependent on it in a significant way.
Another problem with benzos is that they have been associated with later on developing dementia in life. There is still research going on about this. The association is not a hundred percent clear, but I think that's concerning.
And another reason to avoid using them if possible. And what benzos will definitely do is make confusion, memory loss or other symptoms of dementia worse in people who clearly already have developed brain changes. Benzos also do increase falls and worsen balance.
So these are some of the reasons that geriatricians love to hate benzos. This is why we almost never start them on our own patients, and this is why we try to help our older patients get off them if it is at all possible. So let me say a few words now about discontinuing benzodiazepines.
So in general, you always wanna be careful before stopping a medication cold Turkey, but it's more important for some medications than others. And for benzos, it's actually really, really, really important to not stop them cold turkey, if a person has been taking them every day, or quite often it can be very dangerous. So again, benzos work on the same receptors as with alcohol.
And so just as we don't wanna take a heavy drinker and have them quit cold Turkey, they can have life-threatening withdrawal. The same thing applies to benzodiazepines. So if we are trying to stop benzos, we always wanna taper them slowly and under medical supervision.
Now, some people who have been on benzos will say, well, I tried to stop and it didn't work. Tapering benzos can and does work. This has actually been studied in clinical trials that were developed by geriatricians to help people get off these dangerous medications.
So I have a related link about these four types of medications on my website, and if you visit that page over there, I have a link to a special handout that was clinically tested. They would actually give this handout to older adults at the pharmacy when they came to pick up their benzodiazepines. And the handout would inform them of the risks of benzodiazepines, other ways to manage anxiety or insomnia.
And it provided them with a tapering schedule that they could show to their doctor and kind of work from there. And many older adults were successfully tapered from their benzos with this method. So it definitely is possible.
That said, there is one situation where I found that it is quite difficult to get people off of benzodiazepines, and that is when the older person actually has developed ongoing memory loss or has been diagnosed with a condition like Alzheimer's or dementia. So in that case, the thing about tapering benzos is that the older person usually has to experience at least temporarily a little bit of an increase in sleep difficulties or in anxiety as the body adjusts to making do without this medication. And when people have developed Alzheimer's or dementia, they usually have very, very little tolerance for that discomfort.
Their memory gets a lot worse when they're uncomfortable or they get very agitated or it becomes really, really hard for their family to take care ofthem. So we still often try to lower the dose, but I got to tell you, it's hard. Ideally, we don't wanna wait until somebody is frankly having real memory problems before we stop the benzodiazepines, and we also try to reduce them at that point.
It just is much, much harder to do it than if we attempted earlier in their life. Now, before I go onto the other types of medications that I recommend stopping, just a few words about alternatives to benzodiazepines because I don't like to tell people to stop a medication without offering a few other ways that they might manage their symptoms. So first of all, anxiety.
Anxiety is really common right now in the United States in people of all age groups, and there are other ways to manage anxiety. So first of all, there are other prescription medications that have been clinically shown to be effective for anxiety and they don't slow the brain down as much. So in particular, medications in the class of selective ser serotonin reuptake inhibitors, that's a mouthful.
SSRIs, as we say in medicine, are effective for anxiety. So in geriatrics, we especially like escitalopram and sertraline, the brand names for those are Lexapro and Zoloft. Another popular SSRI that you may have heard of is Prozac.
That was the first one that made a big hit in the nineties. Prozac interacts with a lot more medications then Lexapro and Zoloft. That's why we use it less.
So those medications do work for anxiety. They don't work within hours in the same way, but they can be effective when people take them in an ongoing way. And then there are many non-drug therapies that are very effective for anxiety, certain forms of cognitive behavioral therapy or other forms of psychotherapy.
So there are options other than benzos to manage anxiety. As for insomnia, this is another condition where non-medication approaches can and do work and they're much safer. Also, if you are trying to treat insomnia, I highly recommend first making sure that you have had a thorough evaluation for what might be causing the sleep problem.
Because sometimes it can be another health condition that needs treatment such as sleep apnea. Do we ever use medication to treat insomnia or sleep difficulties in geriatrics? Yes, we do.
After we've tried lots of other things, people sometimes ask, is there an easy, safe, fast option to help an older person sleep? Not really. There are some medications though that we would try not benzos if we are working on that.
And those are also mentioned in articles that I have on my site. All right, let me now move on to the next type of medication that I'm looking out for that I consider a brain flowing medication that is worth avoiding, and that would be non benzodiazepine prescription sedatives. These are medications that in medicine, the most commonly prescribed ones right now, because we no longer prescribe barbiturates and some of the other non benzo sedatives that use to exist.
The most common ones right now are what we refer to as Z drugs because all the generic ones start with a Z. And the best known one is Zolpidem brand name Ambien, and then there are a few others. The brand names are Sonata and Lunesta that are also sometimes prescribed.
So these are fairly popular because lots of people do have sleep problems, but we try to avoid them in geriatrics because they again, slow down the brain and they have been shown in clinical studies to impair thinking and balance in older adults the next day. Now, do they also increase the risk of developing something like Alzheimer's disease over time, or if you use them for years and years? We don't really know.
The research on that is kind of, you know, a little bit unclear right now because we actually know that if people are developing Alzheimer's or other forms of dementia, the brain changes start 10 to 15 years before and those can in of themselves interfere with sleep. So that does not mean that if you are having sleep difficulties, you should panic and worry that you're in the early stages of Alzheimer's. That's not very useful to think about.
This is just to say that this is part of why the research has been a little bit hard to sort out on this question. But these medications definitely will affect balance and thinking in older adults. And again, especially if a person is already struggling with memory or thinking or is a lot older, slowing down the brain further is a bad idea.
So that's another type of medication that I look out for and try to discontinue whenever possible. Now, for the third type of medication that I'd like to look out for, this is a group called Anticholinergics. This is a very big group of medications, actually.
It's a, it's a very common medication property, and there are drugs in several different classes that fall into this. This group covers most of the over-the-counter sleeping aids that you might find at the drugstore and antihistamines such as Benadryl, along with many other commonly used prescription drugs. And what these medications all have in common is the chemical property of blocking the neurotransmitter acetylcholine.
So this is a neurotransmitter that first of all, your body definitely needs it for your brain cells to communicate with each other, and your body also uses it elsewhere in the body for certain types of neurons to communicate with each other. And acetylcholine is so important to thinking that actually when they want to develop a medication for Alzheimer's, the medication they developed, donepezil brand name Aricept, is actually designed to boost levels of acetylcholine in the brain. So when people take anticholinergics, they're taking a medication that is the opposite of what we give people to help their brain function if they have been diagnosed with dementia.
So now, which medications are anticholinergic? There are actually so many of them that I have a video that covers seven common types that are very easy to encounter either in the drugstore or easy to be prescribed to. So if you wanna learn more, I highly recommend that video.
But briefly, the medications look out for are sedating antihistamines like Benadryl PM versions of over-the-counter painkillers because they add something like Benadryl to it to make you sleepy. Medications for overactive bladder for vertigo, or motion sickness or nausea medications, oral medications for itching, muscle relaxants, and also an older type of antidepressant that is now usually used for nerve pain or to treat shingles pain. The antidepressant Paxil, which is an SSRI, is also anticholinergic.
And that's interesting because the other medications in the SSRI group are generally much not very anticholinergic. So that's a reason why you'll almost never see a geriatrician prescribed Paxil. So again, if you want to access a longer list of anticholinergics, please see the other video and my related article on Better, Health While Aging.
But in general, a little tip is that you can often recognize anticholinergics because they have very typical anticholinergic side effects. They tend to cause dry eye, dry mouth, constipation and drowsiness. So if you're on a medication that along with its intended effect is giving you dry mouth, chances are good that that is an anticholinergic medication.
Okay, and let me now go through the fourth type of medication that I often look out for and try to stop if possible. And that is anti-psychotics and mood stabilizers. So these are medications that were originally developed to treat serious mental illnesses such as schizophrenia and bipolar disorder.
And they still have a very important role in the treatment of those illnesses. Now, some of the mood stabilizers were originally developed to treat seizures and they might be used for that purpose as well. The thing is, among older adults, I see these medications quite often prescribed to manage difficult behaviors related to Alzheimer's disease and other dementias.
So they might be prescribed for somebody who is having hallucinations or delusions or just extreme paranoia, or often they're prescribed to people who are agitated, which means they get revved up, they get upset, they're uncooperative, or they're making life difficult for other people. So this might be an older person who gets upset when caregivers come to them and try to help them change their clothes or bathe or you know, isn't cooperative with instructions. So here again, it's really important to know that antipsychotics are not FDA approved for this purpose.
In fact, there is a black box warning on them for using them for people with dementia because the research found that when we give these medications to people with dementia, they have a higher chance of dying within the next six to 12 months. So the most commonly prescribed anti-psychotics these days are what's known as second generation, and they include medications such as Risperidone, Quetiapine olanzapine, and Aripripazole. And the brand names for those respectively are Risperdal, Seroquel, Zyprexa, and Abilify.
There's also a first generation antipsychotic that is still used fairly often because it's cheap and pretty effective. And that is Haloperidol brand name Haldol. And then the mood stabilizer that I see often prescribed to some older adults is valproate.
The brand name for that is Depakote. So again, the risk to older people when we use these drugs. So they definitely slow down the brain and thinking.
So when we are using them for behaviors, it is essentially a chemical restraint for agitation. And if you are trying to manage, you know, a very psychosis like symptom, like hallucinations, they can help with that. But it's at the cost of otherwise slowing down the person's brain and thinking and other cognitive abilities.
They also definitely affect balance and can cause falls. And then again, the antipsychotics do increase the risk of dying within the next six to 12 months. And the research shows that the absolute increase in mortality risk is somewhere between 2% and 4%.
So what would be some alternatives to using antipsychotics and mood stabilizers? Well, so again, this is, especially if they're being considered for difficult Alzheimer's behaviors or agitation. If we are talking about a person who has, you know, a history of schizophrenia or bipolar, that is another story.
But if it's for managing agitation or difficult behaviors, we always, always, always want to start off by trying other things to manage the behavior. So in people with dementia, agitation often represents an unmet need. And so it's important to explore and figure out what is that need?
Is the person bored? Are they scared? Do they need reassurance?
Do they need attention? Do they need some stimulation? Are they in pain?
There are many ways that we can explore what is driving the behavior and then usually it's possible to manage it without medication. So when it comes to difficult dementia behaviors, medication should really only be used as a last resort after other approaches have been tried and the smallest effective dose should be used. And if you would like to learn more about managing dementia behaviors with less medication, I definitely have articles about that on my website: Better Health While Aging.
So those are the four kinds of brain slowing medication that are worth avoiding or minimizing, especially if you have any memory concerns or wanna optimize an older person's memory. So again, they were benzodiazepines, non benzodiazepine prescription sedatives, so medications like Ambien, anticholinergics, and then antipsychotics and mood stabilizers. Now what should you do if you have been taking these medications?
So first and foremost, please don't panic. Don't panic, don't panic, it's okay. But I do wanna encourage you to bring it up to your health provider.
So because again, this is a risky medication for older adults. Now this doesn't mean that these kind of medications can't ever be used or that it's always wrong to prescribe these medications, but ideally, if a medication is risky, we wanna only use it as a last resort when safer options have been tried and have failed. And if we're gonna use a risky medication, we wanna use it at the lowest dose possible.
If you're taking one of these medications, especially if you have not yet tried alternative ways to manage your symptoms, it's really important to ask your health provider for help. Now I'm gonna tell you right now the problems that many of you will run into because I work a lot with families and I hear what happens when they talk to doctors. The problem you're going to run into is that you might encounter a little bit of resistance from your provider.
And there are a couple reasons for this. First of all, your doctor is likely very busy. This is not their fault.
This is partly that we have a terrible setup for especially outpatient care where doctors are given very little time with patients. Your doctor also may not be aware that these medications are all that that risky or, or discontinuing because they may not have had enough training in geriatrics. And lastly, for a doctor to revisit a medication that they've been prescribing takes time and effort.
It's not the path of least resistance for them to try to get you off these medications, and it's also often more work for them to try to find, help you get access to these non-drug approaches. You know, like the right kind of therapy for, you know, anxiety or the right kind of assistance to help with sleep problems. In medicine, especially in American medicine where we give doctors very little time, by far the easiest thing is to prescribe a pill.
So you just should be aware that this is definitely worth bringing up and it's gonna work better if you come in prepared to politely advocate for yourself. So for instance, here are some things that you could consider saying. You could consider letting your doctor know that it's a value for you to be on as few medications as possible, save you money, and it's safer as you get older.
So you could say something like, you know, I've thought about it and I've realized that I would like to be on as few medications as possible. You could also say something like, I've also been trying to educate myself, and I recently learned that certain drugs are on a beer's list of medications older adults should avoid. Apparently this medication I'm on is on the beers list.
So I'd like to discuss why I'm on it, what our alternatives be on it, and how we can get me off of it. That would be something that you could try and hopefully your providers will be receptive. You can also potentially talk to a pharmacist for help as well as they're also very knowledgeable about medications, and most of them are familiar with the beers criteria.
Now, what should you do if a provider wants to start you on one of these medications, or maybe they wanna start your loved one who has dementia on one of these medications? I would encourage you to ask to try an alternative treatment first. First of all, ask, are there any non-drug approaches that can help me with this problem?
Because often there are, especially when it comes to things like anxiety and insomnia or many of the conditions for which doctors prescribe anticholinergics, a lot of those have non-drug options as well. And if a drug is necessary, is there one that's not on the beers list that we could start with? If you have to start one of these medications, aim to be on the lowest necessary dose and then pay attention to what is the symptom that is, you know, being treated.
And don't stay on the medication if it's not helping with the symptom. Some of these medications are very effective for certain symptoms and others are actually not, you know, in clinical trials, they haven't been found to be that much more effective than doing nothing or doing a non-drug option. So if it's not helping a lot, what is the point of staying on a risky medication?
So with that, I'm gonna wrap up this video. I hope this has been useful. For more details regarding what I covered in this video, please see my related article on Better Health, While Aging.
You can also subscribe to my channel as I plan to be sharing more video soon about Aging Health and how to help older adults have the best quality of life and wellbeing possible. Take care. Thank you for watching and hope to see you again soon.
