21st March 2024

Nervous system

Tricyclic antidepressants particularly dosulepin should be stopped in those with dementia (risk of worsening cognitive impairment), glaucoma (can worsen), cardiac conductive abnormalities (pro-arrhythmic effects) or prior history of constipation or urinary retention. One should be cautious in prescribing benzodiazepines and hypnotics if a fall has occurred in the past 3 months or if the patient has an acute or chronic respiratory failure (pO2 < 8.0 kPa or PCO2 > 6.5 kPa).

Antipsychotics have a wide range of adverse effects from extra-pyramidal side effects with gait disturbances to urinary incontinence and confusion. The necessity of these drugs should be weighed with the adverse effects, particularly when used long term. With the risk of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) from selective serotonin re-uptake inhibitors (SSRIs), stopping these agents would be appropriate in those with significant hyponatraemia (below 130 mmol/l). Citalopram and escitalopram are causes of QT-interval prolongation and thus must be monitored.

Anticholinergic agents have been linked to impaired cognition and physical decline in the elderly. These drugs can manifest with a wide spectrum of symptoms affecting the central nervous system (delirium, agitation and hallucinations) and peripheral nervous system (blurred vision, photophobia and reduced gastrointestinal peristalsis). The STOPP criteria highlights that these drugs should be stopped in those with a history of persistent bradycardia, heart block or recurrent unexplained syncope.

Anticholinergic burden scale

The anticholinergic burden scale lists the anticholinergic activity of a variety of drugs. A total score of three or more is considered clinically significant.