What exactly is overactive bladder? Well, an overactive bladder is a constellation of symptoms or group of symptoms that include urgency or the sensation that you have to rush to the bathroom and you can’t hold it off.
The definition that used in urology for “frequently” going to the bathroom is more than eight times in 24 hours. Urgency urinary incontinence or leakage of urine that occurs with that sudden desire to go to the bathroom that you can’t delay, and nocturia or waking up at night to urinate are also signs of an overactive bladder.
The Types of Bladder Medication Available
There are two classes of medications for overactive bladder. You might see a group of anticholinergics, and then there’s the beta3 agonists. We’ll talk about these medications, and at the very end we’ll outline the latest research linking these anticholinergics to dementia.
Anticholinergics
So the way Anticholinergics work is they bind to a receptor on the bladder wall. And when they do that they inhibit anything in the body from binding to that receptor. Normally, when the body does bind a molecule to that receptor, it causes the bladder to contract—so this medication is inhibiting bladder contractions or squeezing.
What you can imagine then is if this receptor is not able to be activated, you’re having less strong contraction, so you’re decreasing the contractions. All of this will subsequently decrease the amount of urgency that you feel are that strong desire to go and how severe that urge is, when you get it. It will also give you more time to get to the bathroom, so you have fewer accidents, and it will increase the size of your bladder, and it will give you more time between voids.
So if you’re going very often during the day, it will give you some more space between wanting to rush to the bathroom. Studies have compared giving these medications compared to placebo or like a sugar pill. And indeed, they found that people taking antibiotics did have less incontinence, less urgency episodes, less frequent voids and had a larger volume voided karmic tuition, which means that when they go to the bathroom, they’re emptying more volume of their bladder. This medicine of is a surrogate for telling you how big your bladder is or how much urine your bladder can hold.
Great. So these medications work. So why aren’t people with overactive bladder taking these medications all the time? Well, there are some really significant side effects. These can include blurry vision, constipation, dry eyes, dry mouth. There are also some cognitive changes, so people may have decreased attention and reaction time and may have a little bit of decrease in their short term memory. This doesn’t happen to everybody, but it certainly can happen. As such, these medications are not given to people who already have some baseline signs or symptoms of changes in their cognition or their brain activity. Also, you can’t get these medications if you have any sort of urinary retention.
You should also ask your ophthalmologist if you have narrow angle glaucoma, you have that because that would preclude you from having, getting this medication if you potentially needed it. The same goes if you have what’s called gastroparesis, and gastroparesis is when your gut is low in digesting the food you eat.
Beta3 Agonists
Moving on to the second kind of medication, which is called a beta3 agonist, or, again, the name is Mirabegron of the only medication that’s on the market in the United States right now. And how this medication works is it actually binds to a receptor and it mimics what would normally bind to that receptor and it causes the bladder to relax.
So this medication works by causing a decrease in what we call sensory urgency or the sensation or feeling that you have to go, and also increases your bladder capacity or makes it bigger and allows it to hold more.
This medication has very few side effects, the one that we caution all patients on are making sure you check your blood pressure about a week after starting. It can increase your blood pressure very slightly by about 10 millimeters of mercury, but we do want you to check and make sure that you don’t fall into a category where your blood pressure is too high. Other side effects can include a stuffy nose or headaches, you do want to check with your doctor, if you’re on any medications that you might need to adjust with this medication.
The most common medication that does sometimes require some adjustment of the dose you’re taking is a medication called a beta blocker, or metoprolol, toper, all things like that. Generally speaking, this medication is really well tolerated. A lot of people do pretty well on it. The issue is that is still a brand name medication, which sometimes makes it costly based on insurance. And so despite having a little bit of a better side effect profile, so most people can’t afford it and have to try the other class of medications.
Trulicity is also one of the medications that should be taken with precautions.
The Link With Dementia
Now it’s time to discuss the linkage of Anticholinergics with dementia. Where does that come from? Does that hold any weight? And should you be concerned about it?
Well, there were two major studies that were published relatively recently that go into some significant detail on the linkage of dementia with anticholinergic medications. The first study was published in the British Medical Journal in 2018.
What they did was they looked at a big research database that they had, and they found 40,000 people with dementia, aged 65 and above, and they paired them up with other people in that same database, who were very similar to them in age, other medical problems, other conditions that were important, and they match them up. And they compare the two groups either with dementia and without dementia. And what they specifically looked at was the medications they were on anywhere between four and 20 years before getting the diagnosis of dementia.
They did try to control for what’s called confounding factors, so they looked at things like age, smoking medications, other things that might also cause dementia. And what they found specifically was that bladder medications were associated with a higher risk of getting dementia, if they took the ladder medications anytime between the four and 20 years prior to getting diagnosed with dementia.
Of course, one big criticism of this study is one it’s retrospective, meaning it’s looking at a database. we also don’t know if they were able to control for all confounding factors, because really, we don’t know what causes dementia. And we also can’t control for if they took the medication or if they took any over the counter, anticholinergic medication. There are over the counter, anticholinergic medications available, at least in the United States, and so some people could be taking them who are in the not dementia group.
The other theory that goes along with a lot of this data is that there may be something similar in the group of people who get anticholinergics and the group of people who get dementia, meaning that the actual cause—for example, bladder symptoms—might be preceding their dementia, because we do know that bladder symptoms are sometimes the very first sign of a neurologic problem in some conditions like multiple sclerosis. So that might be that this is actually an indicator of dementia.
And if your bladder symptoms are bad enough, it may be that this is the first symptom that you’re going to see. So again, we don’t know enough. It’s hard to really say that one causes the other All we know is that there is a correlation. So should that stop you from taking medications that might improve your quality of life? It’s ultimately up to you to decide that but if your quality of life is really that poor, then you should really consider taking medications that might help you.
The next study was actually very similar to this first one, and it was published in the Journal of the American Medical Association.And they again, were a group out of England that looked at nearly 60,000 people who had dementia and compared them with a bunch of controls. So nearly 250,000 controls who are again matched to the people with dementia.
What was different about the study was they looked at total standardized daily dosing. So they said, how much anticholinergic do you need to take for their correlation to exist with dementia? This isn’t about causation, because we don’t know if it’s causing dementia or not. But we do know that there is a correlation. What they looked at and found was it actually three years or total standardized daily dosing of equivalent of three years was correlated with dementia. Again, this study was limited in the older population above 65 years of age. And they looked at, again, using antibiotics for any period of time from 11 years prior to the diagnosis up until the diagnosis.
Ultimately, we still don’t know what causes dementia, and it’s really hard to say if anticholinergics specifically are causing dementia, or there’s some combined confounding factor that is common in both groups. The same message applies is that yes, there is a correlation—so you want to use these medications with caution.
Concluding Thoughts
If you notice any changes in yourself or your family member who’s taking an anticholinergic, like they’re forgetful, they’re, they’ve changed some factor in their cognitive mindset, then you would try to take them off those medications. And you should review your medications every time you see your doctor and say, “hey, why am I on this? What is this doing for me?”
Lastly, you should know is that there are third-line therapies for overactive bladder. These include Botox injections in the bladder, a bladder pacemaker called sacral neuromodulation, or there are treatments basically acupuncture called posterior tibial nerve stimulation, which is basically similar to acupuncture that helps improve overactive bladder.