Anticholinergics, Such as Excedrin PM and Tylenol PM, #7 on the List of Top 10 Most Dangerous Drugs

Susanna Sisson's picture

Plants of the Solanaceae family contain various anticholinergic tropane alkaloids such as scopolamine, atropine, and hyoscyamine that have been used in both prescription and over the counter drugs. Anticholinergic drugs block acetylcholine, a nervous system neurotransmitter that is involved in memory and learning. Older adults commonly use over-the-counter drugs with anticholinergic effects as sleep aids and to relieve bladder leakage. This class of drugs is frequently prescribed for many chronic diseases including hypertension, cardiovascular disease, and chronic obstructive pulmonary disease.


Research published in JAMA [2] has found that anticholinergic medicines like Benedryl can lead to cognitive impairment and even potentially irreversible dementia when taken continuously for as few as 60 days. A team led by Shelley Gray, a pharmacist at the University of Washington’s School of Pharmacy, tracked nearly 3,500 men and women ages 65 and older who took part in Adult Changes in Thought (ACT), a long-term study conducted by the University of Washington and Group Health, a Seattle healthcare system. Taking an anticholinergic for the equivalent of three years or more was associated with a 54% higher dementia risk than taking the same dose for three months or less.[2]

These findings are particularly important in the geriatric population who tend to be polypharmic, may have multiple health issues and may be a fall risk due to other factors. What should also be considered and a concern far more than any individual anticholinergic medication is the combination of several drugs with anticholinergic activity. Physicians may not realize that the anti-anxiety agent alprazolam (Xanax) has anticholinergic activity. So does the ulcer drug cimetidine (Tagamet). The dizziness drug meclizine (Antivert, Bonine) also has this activity.

According to the Seattle team of researchers, 8% to 37% are taking such drugs, despite warnings to health professionals that risks might outweigh benefits. What this means is that as many as one-third of people over 65 could be taking an anticholinergic drug without even knowing it or understanding the dangers. If on several such drugs the effects can be synergistic not to mention cumulative. Unfortunately, cognitive decline that is due to anticholinergic medications is often overlooked.

People who are taking over the counter medications should ask their doctor and pharmacist about side effects as well as drug interactions and be sure to share that they are using those drugs. It’s helpful to have a list of medications, herbs and supplements.

Examples of common anticholinergics:


• Amitriptyline (Elavil)
• Atropine
• Benztropine (Cogentin)
• Chlorpheniramine (Actifed, Allergy & Congestion Relief, Chlor-Trimeton, Codeprex, Efidac-24 Chlorpheniramine, etc.)
• Chlorpromazine (Thorazine)
• Clomipramine (Anafranil)
• Clozapine (Clozaril)
• Co-phenotrope (Lomotil)
• Cyclobenzaprine (Amrix, Fexmid, Flexeril)
• Cyproheptadine (Periactin)
• Desipramine (Norpramin)
• Dexchlorpheniramine
• Dicyclomine (Bentyl)
• Diphenhydramine (Advil PM, Aleve PM, Bayer PM, Benadryl, Excedrin PM, Nytol, Simply Sleep, Sominex, Tylenol PM, Unisom, etc.)
• Doxepin (Adapin, Silenor, Sinequan)
• Fesoterodine (Toviaz)
• Hydroxyzine (Atarax, Vistaril)
• Hyoscyamine (Anaspaz, Levbid, Levsin, Levsinex, NuLev)Imipramine (Tofranil)
• Meclizine (Antivert, Bonine)
• Nortriptyline (Pamelor)
• Olanzapine (Zyprexa)
• Orphenadrine (Norflex)
• Oxybutynin (Ditropan, Oxytrol)
• Paroxetine (Brisdelle, Paxil)
• Perphenazine (Trilafon)
• Prochlorperazine (Compazine)
• Promethazine (Phenergan)
• Protriptyline (Vivactil)
• Pseudoephedrine HCl/Triprolidine HCl (Aprodine)
• Scopolamine (Transderm Scop)
• Thioridazine (Mellaril)
• Tolterodine (Detrol)
• Trifluoperazine (Stelazine)
• Trimipramine (Surmontil)

Possible side effects of anticholinergics include:

• Ataxia; loss of coordination
• Decreased mucus production in the nose and throat; consequent dry, sore throat
• Xerostomia or dry-mouth with possible acceleration of dental caries
• Cessation of perspiration; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin
• Increased body temperature
• Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia)
• Loss of accommodation (loss of focusing ability, blurred vision – cycloplegia)
• Double-vision (diplopia)
• Increased heart rate (tachycardia)
• Tendency to be easily startled
• Urinary retention
• Diminished bowel movement, sometimes ileus (decreases motility via the vagus nerve)
• Increased intraocular pressure; dangerous for people with narrow-angle glaucoma
• Shaking
• Confusion
• Disorientation
• Agitation
• Euphoria or dysphoria
• Respiratory depression
• Memory problems
• Inability to concentrate
• Wandering thoughts
• Incoherent speech
• Irritability
• Mental confusion (brain fog)
• Wakeful myoclonic jerking
• Unusual sensitivity to sudden sounds
• Illogical thinking
• Photophobia
• Visual disturbances
• Periodic flashes of light
• Periodic changes in visual field
• Visual snow
• Restricted or “tunnel vision”
• Visual, auditory, or other sensory hallucinations
• Warping or waving of surfaces and edges and textured surfaces
• “Dancing” lines; “spiders”, insects; form constants
• Lifelike objects indistinguishable from reality
• Phantom smoking
• Hallucinated presence of people not actually there
• seizures, coma, and death
• Orthostatic hypotension (sudden dropping of systolic blood pressure when standing up suddenly) and significantly increased risk of falls in the elderly population.

A common mnemonic for the main features of anticholinergic syndrome is the following:

• Hot as a hare (hyperthermia)
• Blind as a bat (dilated pupils)
• Dry as a bone (dry skin)
• Red as a beet (vasodilation)
• Mad as a hatter (hallucinations/agitation)
• The bowel and bladder lose their tone and the heart goes on alone (ileus, urinary retention, tachycardia)