chapter 21

Anticholinergic Drugs
Objectives
AFTER STUDYING THIS CHAPTER, THE STUDENT WILL BE ABLE TO:

1. List characteristics of anticholinergic drugs in 5. Review anticholinergic effects of anti-

terms of effects on body tissues, indications
for use, nursing process implications, observa-
tion of client response, and teaching clients.
2. Discuss atropine as the prototype of anti-
cholinergic drugs.
3. Discuss clinical disorders/symptoms for which
anticholinergic drugs are used.
4. Describe the mechanism by which atropine
relieves bradycardia.
psychotics, tricyclic antidepressants, and
antihistamines.
6. Discuss principles of therapy and nursing
process for using anticholinergic drugs in
special populations.
7. Describe the signs and symptoms of atropine or
anticholinergic drug overdose and its treatment.
8. Teach clients about the safe, effective use of
anticholinergic drugs.

Critical Thinking Scenario

George Wilson, 76 years of age, has been treated for depression with amitriptyline (Elavil) for 5 years.
He is admitted to the hospital for elective surgery, after which he becomes acutely confused. The physician
prescribes haloperidol (Haldol) PRN to control severe agitation. You note in the drug reference text that both
these medications have anticholinergic side effects.

Reflect on:
 Important assessments to detect anticholinergic effects.

 How anticholinergic side effects can be especially significant for the elderly.

 Developing a plan to minimize or manage anticholinergic effects for this client.

DESCRIPTION
Anticholinergic drugs, also called cholinergic blocking and
parasympatholytic agents, block the action of acetylcholine on
the parasympathetic nervous system (PNS). Most anticholin-
ergic drugs interact with muscarinic cholinergic receptors in
the brain, secretory glands, heart, and smooth muscle and are
also called antimuscarinic agents. A few anticholinergic drugs,
when given at high doses, are also able to block nicotinic re-
ceptors in autonomic ganglia and skeletal muscles. Glycopyr-
rolate (Robinul) is an example of such a medication. The
prototype anticholinergic drug is atropine, and this drug class
includes belladonna alkaloids, their derivatives, and many syn-
thetic substitutes.
Most anticholinergic medications are either tertiary
amines or quaternary amines in their chemical structure. Ter-
tiary amines are uncharged lipid-soluble molecules. Atropine
and scopolamine are tertiary amines and therefore are able to
308
cross cell membranes readily. They are well absorbed from
the gastrointestinal (GI) tract and conjunctiva and they cross
the bloodbrain barrier. Tertiary amines are excreted in the
urine. Some belladonna derivatives and synthetic anticholin-
ergics are quaternary amines. These drugs carry a positive
charge and are lipid insoluble. Consequently, they do not read-
ily cross cell membranes. They are poorly absorbed from the GI
tract and do not cross the bloodbrain barrier. Quaternary
amines are excreted largely in the feces. Table 211 lists com-
mon tertiary amine and quaternary amine anticholinergic drugs.
Mechanism of Action and Effects
These drugs act by occupying receptor sites at parasympa-
thetic nerve endings, thereby leaving fewer receptor sites free
to respond to acetylcholine (Fig. 211). Parasympathetic re-
sponse is absent or decreased, depending on the number of
 CHAPTER 21 ANTICHOLINERGIC DRUGS 309

drug of choice to treat symptomatic sinus bradycardia.

Common Tertiary Amine
TABLE 211 and Quaternary Amine Low doses (<0.5 mg) may produce a slight and tempo-
Anticholinergic Drugs rary decrease in heart rate; however, moderate to large
doses (0.5 to 1 mg) increase heart rate by blocking
Tertiary Amines Quarternary Amines parasympathetic vagal stimulation. Although the in-
Atropine Glycopyrrolate (Robinul) crease in heart rate may be therapeutic in bradycardia, it
Benztropine (Cogentin) Ipratropium (Atrovent) can be an adverse effect in patients with other types of
Biperiden (Akineton) Mepenzolate (Cantil) heart disease because atropine increases the myocardial
Dicyclomine hydrochloride (Bentyl) Methscopolamine (Pamine) oxygen demand. Atropine usually has little or no effect
Flavoxate (Urispas) Propantheline bromide
on blood pressure. Large doses cause facial flushing be-
l-Hyoscyamine (Anaspaz) (Pro-Banthine)
Oxybutynin (Ditropan) cause of dilation of blood vessels in the neck.
Procyclidine (Kemadrin) 3. Bronchodilation and decreased respiratory tract se-
Scopolamine cretions. Bronchodilating effects result from blocking
Tolterodine (Detrol and Detrol LA) the bronchoconstrictive effects of acetylcholine. When
Trihexyphenidyl (Trihexy)
anticholinergic drugs are given systemically, respiratory
secretions decrease and may become viscous, resulting
in mucous plugging of small respiratory passages. Ad-
receptors blocked by anticholinergic drugs and the under- ministering the medications by inhalation decreases this
lying degree of parasympathetic activity. Since cholinergic effect while preserving the beneficial bronchodilation
muscarinic receptors are widely distributed in the body, anti- effect.
cholinergic drugs produce effects in a variety of locations, in- 4. Antispasmodic effects in the GI tract due to de-
cluding the central nervous system, heart, smooth muscle, creased muscle tone and motility. The drugs have
glands, and the eye. little inhibitory effect on gastric acid secretion with
Specific effects on body tissues and organs include: usual doses and insignificant effects on pancreatic and
1. Central nervous system (CNS) stimulation followed intestinal secretions.
by depression, which may result in coma and death. 5. Mydriasis and cycloplegia in the eye. Normally, anti-
This is most likely to occur with large doses of anti- cholinergics do not change intraocular pressure, but
cholinergic drugs that cross the bloodbrain barrier with narrow-angle glaucoma, they may increase in-
(atropine, scopolamine, and antiparkinson agents). traocular pressure and precipitate an episode of acute
2. Decreased cardiovascular response to parasympa- glaucoma. When the pupil is fully dilated, photophobia
thetic (vagal) stimulation that slows heart rate. At- may be bothersome, and reflexes to light and accom-
ropine is the anticholinergic drug most often used for its modation may disappear.
cardiovascular effects. According to Advanced Cardiac 6. Miscellaneous effects include decreased secretions
Life Support (ACLS) protocol (2000), atropine is the from salivary and sweat glands; relaxation of ureters,
urinary bladder, and the detrusor muscle; and relaxation
of smooth muscle in the gallbladder and bile ducts.
The clinical usefulness of anticholinergic drugs is limited
by their widespread effects. Consequently, several synthetic
drugs have been developed in an effort to increase selectivity
Nerve ending Presynaptic vesicles of action on particular body tissues, especially to retain the
containing acetylcholine antispasmodic and antisecretory effects of atropine while
eliminating its adverse effects. This effort has been less than
successfulall the synthetic drugs produce atropine-like ad-
verse effects when given in sufficient dosage.
One group of synthetic drugs is used for antispasmodic
Acetylcholine effects in GI disorders. Another group of synthetic drugs in-
cludes centrally active anticholinergics used in the treatment
Anticholinergic Muscarinic of Parkinsons disease (see Chap. 12). They balance the rel-
drug receptor ative cholinergic dominance that causes the movement dis-
orders associated with parkinsonism.

Effector target organ

Figure 211 Mechanism of action of anticholinergic drugs. Anti-
cholinergic (antimuscarinic) blocking agents prevent acetylcholine from
interacting with muscarinic receptors on target effector organs, thus
blocking or decreasing a parasympathetic response in these organs.
Indications for Use
Anticholinergic drugs are used for disorders in many body
systems. Clinical indications for use of anticholinergic drugs
include GI, genitourinary, ophthalmic and respiratory dis-
 310 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM
orders, bradycardia, and Parkinsons disease. They also are
used before surgery and bronchoscopy. Drugs at a Glance:
Selected Anticholinergic Drugs describes the therapeutic use,
dosage and route of administration of selected anticholiner-
gic medications.
GI disorders in which anticholinergics have been used
include peptic ulcer disease, gastritis, pylorospasm, di-
verticulitis, ileitis, and ulcerative colitis. These condi-
tions are often characterized by excessive gastric acid
and abdominal pain because of increased motility and
spasm of GI smooth muscle. In peptic ulcer disease,
more effective drugs have been developed, and anti-
cholinergics are rarely used. The drugs are weak inhibitors
of gastric acid secretion even in maximal doses (which
usually produce intolerable adverse effects). Although
they do not heal peptic ulcers, they may relieve abdom-
inal pain by relaxing GI smooth muscle.
Anticholinergics may be helpful in treating irritable
colon or colitis, but they may be contraindicated in
chronic inflammatory disorders (eg, diverticulitis, ulcer-
ative colitis) or acute intestinal infections (eg, bacterial,
viral, amebic). Other drugs are used to decrease diarrhea
and intestinal motility in these conditions.
In genitourinary disorders, anticholinergic drugs may
be given for their antispasmodic effects on smooth mus-
cle to relieve the symptoms of urinary incontinence and
frequency that accompany an overactive bladder. In
infections such as cystitis, urethritis, and prostatitis, the
drugs decrease the frequency and pain of urination. The
drugs are also given to increase bladder capacity in
enuresis, paraplegia, or neurogenic bladder.
In ophthalmology, anticholinergic drugs are applied
topically for mydriatic and cycloplegic effects to aid
examination or surgery. They are also used to treat
some inflammatory disorders. Anticholinergic prepa-
rations used in ophthalmology are discussed further in
Chapter 65.
In respiratory disorders characterized by bronchocon-
striction (ie, asthma, chronic bronchitis), ipratropium
(Atrovent) may be given by inhalation for bronchodi-
lating effects (see Chap. 47).
In cardiology, atropine may be given to increase heart
rate in bradycardia and heart block characterized by
hypotension and shock.
In Parkinsons disease, anticholinergic drugs are given
for their central effects in decreasing salivation, spas-
ticity, and tremors. They are used mainly in clients who
have minimal symptoms, who do not respond to lev-
odopa, or who cannot tolerate levodopa because of ad-
verse reactions or contraindications. An additional use
of anticholinergic drugs is to relieve Parkinson-like
symptoms that occur with older antipsychotic drugs.
Before surgery, anticholinergics are given to prevent
vagal stimulation and potential bradycardia, hypoten-
sion, and cardiac arrest. They are also given to reduce
respiratory tract secretions, especially in head and neck
surgery and bronchoscopy.
Contraindications to Use
Contraindications to the use of anticholinergic drugs include
any condition characterized by symptoms that would be ag-
gravated by the drugs. Some of these are prostatic hypertrophy,
myasthenia gravis, hyperthyroidism, glaucoma, tachyarrhyth-
mias, myocardial infarction, and heart failure unless bradycar-
dia is present. They should not be given in hiatal hernia or other
conditions contributing to reflux esophagitis because the drugs
delay gastric emptying, relax the cardioesophageal sphincter,
and increase esophageal reflux.
INDIVIDUAL
ANTICHOLINERGIC DRUGS
Belladonna Alkaloids and Derivatives
Atropine, the prototype of anticholinergic drugs, produces
the same effects, has the same clinical indications for use, and
has the same contraindications as those described earlier. In
addition, it is used as an antidote for an overdose of choliner-
gic drugs and exposure to insecticides that have cholinergic
effects.
Atropine is a naturally occurring belladonna alkaloid that
can be extracted from the belladonna plant or prepared syn-
thetically. It is usually prepared as atropine sulfate, a salt that
is very soluble in water. It is well absorbed from the GI tract
and distributed throughout the body. It crosses the bloodbrain
barrier to enter the CNS, where large doses produce stimulant
effects and toxic doses produce depressant effects. Atropine is
also absorbed systemically when applied locally to mucous
membranes. The drug is rapidly excreted in the urine. Phar-
macologic effects are of short duration except for ocular
effects, which may last for several days.
Belladonna tincture is a mixture of alkaloids in an aqueous-
alcohol solution. It is most often used in GI disorders for anti-
spasmodic effect. It is an ingredient in several drug mixtures.
Homatropine hydrobromide (Homapin) is a semisyn-
thetic derivative of atropine used as eye drops to produce my-
driasis and cycloplegia. Homatropine may be preferable to
atropine because ocular effects do not last as long.
Hyoscyamine (Anaspaz) is a belladonna alkaloid used
in GI and genitourinary disorders characterized by spasm,
increased secretion, and increased motility. It has the same
effects as other atropine-like drugs.
Ipratropium (Atrovent) is an anticholinergic drug chemi-
cally related to atropine. When given as a nasal spray, it is use-
ful in treating rhinorrhea due to allergy or the common cold.
When given as an inhalation treatment or aerosol to patients
with chronic obstructive pulmonary disease (COPD), it is ben-
eficial as a bronchodilator. An advantage of administration of
anticholinergic drugs by the respiratory route over systemic ad-
ministration is less thickening of respiratory secretions and re-
duced incidence of mucus-plugged airways.
Scopolamine is similar to atropine in uses, adverse
effects, and peripheral effects but different in central effects.

Drugs at a Glance: Selected Anticholinergic Drugs
Generic/Trade Name
Belladonna Alkaloids and Derivatives
Atropine
Ophthalmic atropine (Isopto-Atropine)
Homatropine (Homapin)
Hyoscyamine (Anaspaz)
Ipratropium (Atrovent)
Scopolamine
Use
Systemic use
Surgery
Bradyarrythmias
Antidote for cholinergic poisoning
Mydriatic/cycloplegia/
inflammation of uveal tract
Mydriatic/cycloplegia/
inflammation of uveal tract
Antispasmodic Antisecretory
for gastrointestinal (GI) and
genitourinary (GU) disorders
Bronchodilation
Nasal spray for rhinorrhea
Systemic use
Antiemetic
Mydriatic/cycloplegia/
inflammation of uveal tract
CHAPTER 21 ANTICHOLINERGIC DRUGS 311
Routes and Dosage Ranges
Adults Children
PO, IM, SC, IV 0.40.6 mg PO, IM, SC, IV:
716 lbs: 0.1 mg
1624 lbs: 0.15 mg
2440 lbs: 0.2 mg
4065 lbs: 0.3 mg
6590 lbs: 0.4 mg
>90 lbs 0.40.6 mg
IM, SC, or IV 0.40.6 mg prior 0.1 mg (newborn) to 0.6 mg
to induction. Use 0.4-mg (12 y) given SC 30 min prior
dose with cyclopropane to surgery.
anesthesia.
IV 0.41 mg (up to 2 mg)
q12h PRN.
IV titrate large doses of 23 mg
as needed until signs of
atropine toxicity appear and
cholinergic crisis is controlled.
For refraction: Instill 12 drops For refraction: Instill 12 drops
of 1% solution into eye(s) 1 h of 0.5% solution bid for
before refraction. 13 days before procedure.
For uveitis: Instill 12 drops of
1% solution into eye(s) qid.
For refraction: Instill 12 drops For refraction: Instill 1 drop of
of 2% solution or 1 drop 2% solution into eye before
5% solution into eye before procedure. May repeat q 10
procedure. May repeat at min as needed. For uveitis:
510 min intervals as Instill 1 drop of 2% solution
needed. bid to tid.
For uveitis: Instill 12 drops of
2% or 5% solution bid to tid
or every 34 h as needed.
PO, SL 0.1250.25 mg tid or Children 210 y: PO
qid, ac and hs. PO (timed- 0.0620.125 mg q 68h.
release formula): Children <2 y: half of the
0.3750.75 q12h. IM, IV, previous dose.
SC: 0.250.5 mg q6h.
2 puffs (36 mcg) of aerosol qid.
Additional inhalations may
be needed. Do not exceed
12 puffs/24h. Solution for
inhalation: 500 mcg, tidqid.
2 sprays/nostril of 0.03% spray 2 sprays/nostril of 0.03% spray
bidtid. bidtid.
2 sprays/nostril of 0.06% spray
tidqid.
PO 0.40.8 mg qd. Not approved for PO use <6 y.
SC, IM 0.320.65 mg Parenteral: 0.006 mg/kg.
IV 0.320.65 mg diluted in Maximum dose: 0.3 mg.
sterile water for injection.
Transdermal: Apply disc 4 h Not approved in children.
before antiemetic effect is
needed. Replace q 3 days.
For refraction: Instill 12 drops Same as adult dose
into eye 1 h before refracting.
For uveitis: Instill 12 drops
into eye(s) up to tid.
(continued )
 312 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM

Drugs at a Glance: Selected Anticholinergic Drugs (continued )

Routes and Dosage Ranges

Generic/Trade Name Use Adults Children

Antisecretory/Antispasmodic Anticholinergics for GI Disorders

Dicyclomine hydrochloride (Bentyl)
Glycopyrrolate (Robinul)
Mepenzolate (Cantil)
Methscopolamine (Pamine)
Propantheline bromide (Pro-Banthine)
Anticholinergics Used in Parkinsons Disease
Benztropine (Cogentin)
Biperiden (Akineton)
Procyclidine (Kemadrin)
Trihexyphenidyl (Trihexy)
Urinary Antispasmodics
Flavoxate (Urispas)
Oxybutynin (Ditropan and Ditropan XL)
Tolterodine (Detrol and Detrol LA)
Antisecretory/antispasmodic
Antisecretory/antispasmodic
Preanesthetic
Antisecretory/antispasmodic
Antisecretory/antispasmodic
Antisecretory/antispasmodic
Parkinsonism
Drug-induced extrapyramidal
symptoms
Parkinsonism
Drug-induced extrapyramidal
symptoms
Parkinsonism
Drug-induced extrapyramidal
symptoms
Parkinsonism
Drug-induced extrapyramidal
symptoms
PO 2040 mg ac & hs
IM 20 mg ac & hs
PO 12 mg bidtid < 12 y: not recommended
IM, IV 0.10.2 mg
IM 0.004 mg/kg 3060 min <2 y: 0.004 mg/lb IM
before anesthesia 3060 min before
anesthesia.
212 y: 0.0020.004 mg/lb
IM 3060 min before
anesthesia.
PO 2550 mg qid ac & hs
PO 2.55 mg 30 min ac & hs 200 mcg/kg ac & hs
PO 7.515 mg 30 min ac & hs
PO, IM, IV 0.51 mg hs. May
increase up to 6 mg given hs
or in 24 divided doses.
For acute dystonia: IM, IV 12
mg. May repeat if needed.
For prevention: PO 12 mg.
PO 2 mg tidqid. Maximum
dose 16 mg/day.
PO 2 mg tidqid
IM, IV 2 mg. Repeat q12h
until symptoms are resolved.
Do not give more than
4 doses/24h
PO 2.5 mg tid pc. May increase
to 5 mg tid.
PO 2.5 mg tid. Increase by
2.5-mg increments until symp-
toms are resolved. Usual
maximum dose 1020 mg/d.
PO 12 mg. Increase by 2 mg
increments at 35-d intervals
until a total of 610 mg is
given qd in divided doses
34 times/d at mealtimes
and bedtimes.
PO 1 mg initially. Increase as
needed to control symptoms.
PO 100200 mg tidqid. <12 y: safety and efficacy not
Reduce when symptoms established
improve.
PO 5 mg bid or tid. >5 y: 5 mg PO bid. Maximum
Maximum dose 5 mg qid. dose 5 mg tid.
Extended-release 5 mg PO qd
up to 30 mg/d.
PO 2 mg bid. May decrease to Safety and efficacy not
1 mg when symptoms im- established.
prove. Reduce doses to
1 mg PO bid in presence of
hepatic impairment.

ac, before meals; hs, bedtime; pc, after meals.


When given parenterally, scopolamine depresses the CNS
and causes amnesia, drowsiness, euphoria, relaxation, and
sleep. Effects of scopolamine appear more quickly and dis-
appear more readily than those of atropine. Scopolamine
also is used in motion sickness. It is available as oral tablets
and as a transdermal adhesive disc that is placed behind the
ear. The disc (Transderm-V) protects against motion sick-
ness for 72 hours.
Centrally Acting Anticholinergics
Used in Parkinsons Disease
Older anticholinergic drugs such as atropine are rarely used to
treat Parkinsons disease because of their undesirable periph-
eral effects (eg, dry mouth, blurred vision, photophobia, con-
stipation, urinary retention, and tachycardia). Newer, centrally
acting synthetic anticholinergic drugs are more selective for
muscarinic receptors in the CNS and are designed to produce
fewer side effects.
Trihexyphenidyl (Trihexy) is used in the treatment of
parkinsonism and extrapyramidal reactions caused by some
antipsychotic drugs. Trihexyphenidyl relieves smooth mus-
cle spasm by a direct action on the muscle and by inhibiting
the PNS. The drug supposedly has fewer side effects than at-
ropine, but approximately half the recipients report mouth
dryness, blurring of vision, and other side effects common to
anticholinergic drugs. Trihexyphenidyl requires the same
precautions as other anticholinergic drugs and is contraindi-
cated in glaucoma. Biperiden (Akineton) and procyclidine
(Kemadrin) are chemical derivatives of trihexyphenidyl and
have similar actions.
Benztropine (Cogentin) is a synthetic drug with both an-
ticholinergic and antihistaminic effects. Its anticholinergic
activity approximates that of atropine. A major clinical use is
to treat acute dystonic reactions caused by antipsychotic
drugs and to prevent their recurrence in clients receiving
long-term antipsychotic drug therapy. It also may be given in
small doses to supplement other antiparkinson drugs. In full
dosage, adverse reactions are common.
Urinary Antispasmodics
Flavoxate (Urispas) was developed specifically to counter-
act spasm in smooth muscle tissue of the urinary tract. It has
anticholinergic, local anesthetic, and analgesic effects. Thus,
the drug relieves dysuria, urgency, frequency, and pain with
genitourinary infections, such as cystitis and prostatitis.
Nursing Notes: Apply Your Knowledge
Scott Andrews is scheduled for a bronchoscopy. Before this
procedure, you have been ordered to give him Valium and at-
ropine. Explain the rationale of giving an anticholinergic agent
as a preoperative medication.
CHAPTER 21 ANTICHOLINERGIC DRUGS 313
How Can You Avoid This Medication Error?
Sam Miller is admitted for elective surgery. He has a history of
heart disease, glaucoma, and benign prostatic hyperplasia (BPH).
After surgery, a scopolamine patch is prescribed to control nausea.
You administer the patch, as ordered, placing it on his chest in a
nonhairy area.
Oxybutynin (Ditropan and Ditropan XL) has direct anti-
spasmodic effects on smooth muscle and anticholinergic ef-
fects. It increases bladder capacity and decreases frequency
of voiding in clients with neurogenic bladder. Oxybutynin is
now available in an extended-release form for once a day
dosing.
Tolterodine (Detrol and Detrol LA) is a competitive anti-
muscarinic, anticholinergic agent that inhibits bladder con-
traction, decreases detrusor muscle pressure, and delays the
urge to void. It is used to treat urinary frequency, urgency, and
urge incontinence. Tolterodine is more selective for muscarinic
receptors in the urinary bladder than other areas of the body,
such as the salivary glands, and therefore anticholinergic side
effects are less marked. Reduced doses (of 1 mg) are recom-
mended for those with hepatic dysfunction. Tolterodine is also
available in an extended-release form.
Nursing Process
Assessment
Assess the clients condition in relation to disorders for
which anticholinergic drugs are used (ie, check for brady-
cardia or heart block, diarrhea, dysuria, abdominal pain,
and other disorders). If the client reports or medical records
indicate a specific disorder, assess for signs and symptoms
of that disorder (eg, Parkinsons disease).
Assess for disorders in which anticholinergic drugs are
contraindicated (eg, glaucoma, prostatic hypertrophy, re-
flux esophagitis, myasthenia gravis, hyperthyroidism).
Assess use of other drugs with anticholinergic effects,
such as antihistamines (histamine-1 receptor antagonists
[see Chap. 48]), antipsychotic agents, and tricyclic anti-
depressants.
Nursing Diagnoses
Impaired Urinary Elimination: Decreased bladder tone
and urine retention
Constipation related to slowed GI function
Disturbed Thought Processes: Confusion, disorientation,
especially in older adults
Deficient Knowledge: Drug effects and accurate usage
Risk for Injury related to drug-induced blurred vision and
photophobia
Risk for Noncompliance related to adverse drug effects
Risk for Altered Body Temperature: Hyperthermia
 314 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM
Planning/Goals
The client will:
Receive or self-administer the drugs correctly
Experience relief of symptoms for which anticholinergic
drugs are given
Be assisted to avoid or cope with adverse drug effects on
vision, thought processes, bowel and bladder elimination,
and heat dissipation
Interventions
Use measures to decrease the need for anticholinergic drugs.
For example, with peptic ulcer disease, teach the client to
avoid factors known to increase gastric secretion and GI
motility (alcohol; cigarette smoking; caffeine-containing
beverages, such as coffee, tea, and cola drinks; ulcerogenic
drugs, such as aspirin). Late evening snacks also should be
avoided because increased gastric acid secretion occurs ap-
proximately 90 minutes after eating and may cause pain and
awakening from sleep. Although milk was once considered
an ulcer food, it contains protein and calcium, which pro-
mote acid secretion, and is a poor buffer of gastric acid. Thus,
drinking large amounts of milk should be avoided.
Evaluation
Interview and observe in relation to safe, accurate drug
administration.
Interview and observe for relief of symptoms for which
the drugs are given.
Interview and observe for adverse drug effects.
PRINCIPLES OF THERAPY
Use in Specific Conditions
Renal or Biliary Colic
Atropine is sometimes given with morphine or meperidine to
relieve the severe pain of renal or biliary colic. It acts mainly
to decrease the spasm-producing effects of the opioid anal-
gesics. It has little antispasmodic effect on the involved mus-
cles and is not used alone for this purpose.
Preoperative Use in Clients With Glaucoma
Glaucoma is usually listed as a contraindication to anticholin-
ergic drugs because the drugs impair outflow of aqueous humor
and may cause an acute attack of glaucoma (increased intra-
ocular pressure). However, anticholinergic drugs can be given
safely before surgery to clients with open-angle glaucoma
(80% of clients with primary glaucoma) if they are receiving
miotic drugs, such as pilocarpine. If anticholinergic pre-
operative medication is needed in clients predisposed to angle
closure, the hazard of causing acute glaucoma can be mini-
mized by also giving pilocarpine eye drops and acetazolamide
(Diamox).
Gastrointestinal Disorders
When anticholinergic drugs are given for GI disorders, larger
doses may be given at bedtime to prevent pain and awaken-
ing during sleep.
Parkinsonism
When these drugs are used in parkinsonism, small doses are
given initially and gradually increased. This regimen decreases
adverse reactions.
Extrapyramidal Reactions
When used in drug-induced extrapyramidal reactions
(parkinson-like symptoms), these drugs should be prescribed
only if symptoms occur. They should not be used routinely to
prevent extrapyramidal reactions because fewer than half the
clients taking antipsychotic drugs experience such reactions.
Most drug-induced reactions last approximately 3 months and
do not recur if anticholinergic drugs are discontinued at that
time. (An exception is tardive dyskinesia, which does not re-
spond to anticholinergic drugs and may be aggravated by them.)
Muscarinic Agonist Poisoning
Atropine is the antidote for poisoning by muscarinic ago-
nists such as certain species of mushrooms, cholinergic ag-
onist drugs, cholinesterase inhibitor drugs, and insecticides
containing organophosphates. Symptoms of muscarinic poi-
soning include salivation, lacrimation, visual disturbances,
bronchospasm, diarrhea, bradycardia, and hypotension.
Atropine blocks the poison from interacting with the mus-
carinic receptor, thus reversing the toxic effects.
Asthma
Oral anticholinergics are not used to treat asthma and other
chronic obstructive pulmonary diseases because of their ten-
dency to thicken secretions and form mucus plugs in airways.
Ipratropium (Atrovent) may be given by inhalation to produce
bronchodilation without thickening of respiratory secretions.
Toxicity of Anticholinergics:
Recognition and Management
Overdosage of atropine or other anticholinergic drugs pro-
duces the usual pharmacologic effects in a severe and exag-
gerated form. The anticholinergic overdose syndrome is
characterized by hyperthermia; hot, dry, flushed skin; dry
mouth; mydriasis; delirium; tachycardia; ileus; and urinary re-
tention. Myoclonic movements and choreoathetosis may be
seen. Seizures, coma, and respiratory arrest may also occur.
Treatment involves use of activated charcoal to absorb ingested
poison. Hemodialysis, hemoperfusion, peritoneal dialysis, and
repeated doses of charcoal are not effective in removing anti-
cholinergic agents.

CLIENT TEACHING GUIDELINES
Anticholinergic Drugs
General Considerations
Do not take other drugs without the physicians knowl-
edge. In addition to some prescribed antiparkinson drugs,
antidepressants, antihistamines, and antipsychotic drugs
with anticholinergic properties, over-the-counter sleeping
pills and antihistamines have anticholinergic effects. Tak-
ing any of these concurrently could cause overdosage or
excessive anticholinergic effects.
Use measures to minimize risks of heat exhaustion and
heat stroke:
Wear light, cool clothing in warm climates or envi-
ronments.
Maintain fluid and salt intake if not contraindicated.
Limit exposure to direct sunlight.
Limit physical activity.
Take frequent cool baths.
Ensure adequate ventilation, with fans or air condi-
tioners if necessary.
Avoid alcoholic beverages.
Use sugarless chewing gum and hard candy, if not con-
traindicated, to relieve mouth dryness.
Carry out good dental hygiene practices (eg, regular
brushing of teeth) to prevent dental caries and loss of
teeth that may result from drug-induced xerostomia (dry
mouth from decreased saliva production). This is more
likely to occur with long-term use of these drugs.
Physostigmine salicylate (Antilirium), an acetylcholineste-
rase inhibitor, is a specific antidote. It is usually given intra-
venously (IV) at a slow rate of injection. Adult dosage is 2 mg
(no more than 1 mg/minute); child dosage is 0.5 to 1 mg
(no more than 0.5 mg/minute). Rapid administration may
cause bradycardia, hypersalivation (with subsequent respira-
tory distress), and seizures. Repeated doses may be given if
life-threatening dysrhythmias, convulsions, or coma occur.
Diazepam (Valium) or a similar drug may be given for ex-
cessive CNS stimulation (delirium, excitement). Ice bags,
cooling blankets, and tepid sponge baths may help reduce
fever. Artificial ventilation and cardiopulmonary resuscita-
tive measures are used if excessive depression of the CNS
causes coma and respiratory failure. Infants, children, and the
elderly are especially susceptible to the toxic effects of anti-
cholinergic agents.
Use in Children
Systemic anticholinergics, including atropine, glycopyrrolate
(Robinul), and scopolamine, are given to children of all ages
for essentially the same effects as for adults. Most of the anti-
secretory, antispasmodic agents for gastrointestinal disorders
are not recommended for children. With the urinary anti-
CHAPTER 21 ANTICHOLINERGIC DRUGS 315
To prevent injury due to blurring of vision or drowsiness,
avoid potentially hazardous activities (eg, driving or oper-
ating machinery).
To reduce sensitivity to light (photophobia), dark glasses
can be worn outdoors in strong light.
Contact lens wearers who experience dry eyes may need
to use an ophthalmic lubricating solution.
When using anticholinergic ophthalmic preparations, if
eye pain occurs, stop using the medication and contact
your physician or health care provider. This may be a
warning sign of undiagnosed glaucoma.
Notify your physician or health care provider if urinary re-
tention or constipation occurs.
Tell your physician or health care provider if you are preg-
nant or breast-feeding or allergic to sulfite preservatives
or any other atropine compound.
Self-Administration
Take anticholinergic drugs for gastrointestinal disorders
30 minutes before meals and at bedtime.
Safeguard anticholinergic medications from children be-
cause they are especially sensitive to atropine poisoning.
To prevent constipation, use a diet high in fiber. Include
whole grains, fruits, and vegetables in your daily menu.
Also, drink 2 to 3 quarts of fluid a day and exercise
regularly.
spasmodics, flavoxate is not recommended for children
younger than 12 years, oxybutynin is not recommended for
children younger than 5 years of age, and the safety and effi-
cacy of tolterodine are not established in children.
The drugs cause the same adverse effects in children as in
adults. However, they may be more severe because children
are especially sensitive to the drugs. Facial flushing is com-
mon in children, and a skin rash may occur.
Ophthalmic anticholinergic drugs are used for cycloplegia
and mydriasis before eye examinations and surgical proce-
dures (see Chap. 65). They should be used only with close
medical supervision. Cyclopentolate (Cyclogyl) and tropi-
camide (Mydriacyl) have been associated with behavioral dis-
turbances and psychotic reactions in children. Tropicamide
also has been associated with cardiopulmonary collapse.
Use in Older Adults
Anticholinergic drugs are given for the same purposes as in
younger adults. In addition to the primary anticholinergic
drugs, many others that are commonly prescribed for older
adults have high anticholinergic activity. These include many
antihistamines (histamine-1 receptor antagonists), tricyclic
antidepressants, and antipsychotic drugs.
 316 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM
Older adults are especially likely to have significant ad-
verse reactions because of slowed drug metabolism and the
frequent presence of several disease processes. Some com-
mon adverse effects and suggestions for reducing their im-
pact are:
Blurred vision. The client may need help with ambula-
tion, especially with stairs or other potentially haz-
ardous environments. Remove obstacles and hazards
when possible.
Confusion. Provide whatever assistance is needed to
prevent falls and other injuries.
Heat stroke. Help to avoid precipitating factors, such as
strenuous activity and high environmental temperatures.
Constipation. Encourage or assist with an adequate in-
take of high-fiber foods and fluids and adequate exercise
when feasible.
Urinary retention. Encourage adequate fluid intake
and avoid high doses of the drugs. Men should be ex-
amined for prostatic hypertrophy.
Hallucinations and other psychotic symptoms.
These are most likely to occur with the centrally active
anticholinergics given for Parkinsons disease or drug-
induced extrapyramidal effects, such as trihexyphenidyl
or benztropine. Dosage of these drugs should be carefully
regulated and supervised.
Use in Renal Impairment
Anticholinergic agents that have a tertiary amine structure,
such as atropine, are eliminated by a combination of hepatic
metabolism and renal excretion. In the presence of renal im-
pairment, they may accumulate and cause increased adverse
effects. Quaternary amines are eliminated largely in the feces
and are less affected by renal impairment.
Use in Hepatic Impairment
Because some anticholinergic drugs are metabolized by the
liver, they may accumulate and cause adverse effects in the
presence of hepatic impairment. Tolterodine is an example of
such a medication. In the presence of liver impairment,
dosages should be reduced and given less frequently.
Use in Critical Illness
Atropine is an important drug in the emergency drug box. Ac-
cording to ACLS guidelines, atropine is the first drug to be ad-
ministered in the emergency treatment of bradyarrhythmias.
Atropine 0.5 to 1 mg should be administered IV every 5 min-
utes and may be repeated up to 2 to 3 mg (0.03 to 0.04 mg/kg
total dose). For clients with asystole, 1 mg of atropine is ad-
ministered IV and repeated every 3 to 5 minutes if asystole
persists, up to 0.04 mg/kg. Administration of atropine in doses
less than 0.5 mg should be avoided because this may result in
a paradoxical bradycardia. Atropine may be administered by
endotracheal tube in clients without an intravenous access.
The recommended dose is 2 to 3 mg diluted in 10 mL normal
saline.
Abuse of Anticholinergic Agents
Anticholinergic drugs have potential intoxicating effects.
Abuse of these drugs may produce euphoria, disorientation,
hallucinations, and paranoia in addition to the classic anti-
cholinergic adverse reactions.
Home Care
Anticholinergic medications are commonly used in home
care with children and adults. Children and older adults are
probably most likely to experience adverse effects of these
drugs and should be monitored carefully. With elderly clients,
the home care nurse needs to assess medication regimens for
combinations of drugs with anticholinergic effects, espe-
cially if mental confusion develops or worsens. The home
care nurse may also need to teach elderly clients or care-
givers that the drugs prevent sweating and heat loss and in-
crease risks of heat stroke if precautions to avoid overheating
are not taken.

NURSING
ACTIONS Anticholinergic Drugs
NURSING ACTIONS
1. Administer accurately
a. For gastrointestinal disorders, give most oral anticholiner-
gic drugs approximately 30 min before meals and at bedtime.
b. When given before surgery, parenteral preparations of at-
ropine can be mixed in the same syringe with several other
common preoperative medications, such as meperidine (De-
merol), morphine, oxymorphone (Numorphan), and promet-
hazine (Phenergan).
c. When applying topical atropine solutions or ointment to the
eye, be sure to use the correct concentration and blot any ex-
cess from the inner canthus.
d. If propantheline is to be given intravenously, dissolve the
30-mg dose of powder in no less than 10 mL of sterile water
for injection.
e. Instruct clients to swallow oral propantheline tablets, not to
chew them.
f. Parenteral glycopyrrolate can be given through the tubing
of a running intravenous infusion of physiologic saline or lac-
tated Ringers solution.
g. Do not crush extended-release forms of anticholinergic drugs
such as Detrol LA and Ditropan XL.
2. Observe for therapeutic effects
a. When a drug is given for peptic ulcer disease or other gastro-
intestinal disorders, observe for decreased abdominal pain.
b. When the drug is given for diagnosing or treating eye dis-
orders, observe for pupil dilation (mydriasis) and blurring of
vision (cycloplegia).
c. When the drug is given for symptomatic bradycardia, observe
for increased pulse rate.
d. When the drug is given for urinary tract disorders, such
as cystitis or enuresis, observe for decreased frequency of uri-
nation. When the drug is given for renal colic due to stones,
observe for decreased pain.
e. When the centrally acting anticholinergics are given for
Parkinsons disease, observe for decrease in tremor, salivation,
and drooling.
CHAPTER 21 ANTICHOLINERGIC DRUGS 317
RATIONALE/EXPLANATION
To allow the drugs to reach peak antisecretory effects by the time
ingested food is stimulating gastric acid secretion. Bedtime ad-
ministration helps prevent awakening with abdominal pain.
The primary reason for mixing medications in the same syringe is
to decrease the number of injections and thus decrease client dis-
comfort. Note, however, that extra caution is required when mixing
drugs to be sure that the dosage of each drug is accurate. Also, if any
question exists regarding compatibility with another drug, it is safer
not to mix the drugs, even if two or three injections are required.
Atropine ophthalmic preparations are available in several concen-
trations (usually 1%, 2%, and 3%). Excess medication should be
removed so the drug will not enter the nasolacrimal (tear) ducts
and be absorbed systemically through the mucous membrane of
the nasopharynx or be carried to the throat and swallowed.
Parenteral administration is reserved for clients who cannot take
the drug orally.
The tablets have a hard sugar coating to mask the bitter taste of
the drug.
Crushing long-acting medications may result in high blood levels
of the medication and increased adverse effects.
Therapeutic effects depend primarily on the reason for use. Thus,
a therapeutic effect in one condition may be a side effect or an ad-
verse reaction in another condition.
Relief of abdominal pain is due to the smooth muscle relaxant or
antispasmodic effect of the drug.
Note that these ocular effects are side effects when the drugs are
given for problems not related to the eyes.
These drugs increase heart rate by blocking action of the vagus
nerve.
Anticholinergic drugs decrease muscle tone and spasm in the
smooth muscle of the ureters and urinary bladder.
Decreased salivation is a therapeutic effect with parkinsonism but
an adverse reaction in most other conditions.
(continued )
318 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM
NURSING ACTIONS
3. Observe for adverse effects
a. Tachycardia
b. Excessive central nervous system (CNS) stimulation (tremor,
restlessness, confusion, hallucinations, delirium) followed by
excessive CNS depression (coma, respiratory depression)
c. Sedation and amnesia with scopolamine or benztropine
(Cogentin)
d. Constipation or paralytic ileus
e. Decreased oral and respiratory tract secretions, which cause
mouth dryness and thick respiratory secretions
f. Urinary retention
g. Hot, dry skin; fever; heat stroke
h. Ocular effects-mydriasis, blurred vision, photophobia
4. Observe for drug interactions
a. Drugs that increase effects of anticholinergic drugs: Anti-
histamines, disopyramide, phenothiazines, thioxanthene agents,
tricyclic antidepressants and amantadine
b. Drugs that decrease effects of anticholinergic drugs: Cholin-
ergic drugs
RATIONALE/EXPLANATION
These depend on reasons for use and are dose related.
Tachycardia may occur with usual therapeutic doses because anti-
cholinergic drugs block vagal action, which normally slows heart
rate. Tachycardia is not likely to be serious except in clients with
underlying heart disease. For example, in clients with angina pec-
toris, prolonged or severe tachycardia may increase myocardial
ischemia to the point of causing an acute attack of angina (chest pain)
or even myocardial infarction. In clients with congestive heart fail-
ure, severe or prolonged tachycardia can increase the workload of the
heart to the point of causing acute heart failure or pulmonary edema.
These effects are more likely to occur with large doses of atropine
because atropine crosses the blood-brain barrier. Large doses of
trihexyphenidyl (Trihexy) also may cause CNS stimulation.
This may be a therapeutic effect but becomes an adverse reaction if
severe or if the drug is given for another purpose. Benztropine has
anticholinergic and antihistaminic properties. Apparently, drowsi-
ness and sedation are caused by the antihistaminic component.
These effects are the result of decreased gastrointestinal motility
and muscle tone. Constipation is more likely with large doses or
parenteral administration. Paralytic ileus is not likely unless the
drugs are given to clients who already have decreased gastro-
intestinal motility.
Mouth dryness is more annoying than serious in most cases and is
caused by decreased salivation. However, clients with chronic
lung disease, who usually have excessive secretions, tend to retain
them with the consequence of frequent respiratory tract infections.
This reaction is caused by loss of bladder tone and is most likely
to occur in elderly men with enlarged prostate glands. Thus, the
drugs are usually contraindicated with prostatic hypertrophy.
These effects are due to decreased sweating and impairment of the
normal heat loss mechanism. Fever may occur with any age group.
Heat stroke is more likely to occur with cardiovascular disease,
strenuous physical activity, and high environmental temperatures,
especially in elderly people.
These are adverse effects when anticholinergic drugs are given for
conditions not related to the eyes.
These drugs have anticholinergic properties and produce additive
anticholinergic effects.
These drugs counteract the inhibition of gastrointestinal motility
and tone induced by atropine. They are sometimes used in atropine
overdose.

Nursing Notes: Apply Your Knowledge
Answer: Although anticholinergic medications are no longer
used routinely as preoperative medication, they are still used in
some preoperative situations when decreased secretions in the
respiratory tract are important. Also, anticholinergic agents block
excessive vagal stimulation by the parasympathetic nervous sys-
tem, which can occur after administration of some anesthetics or
muscle relaxants (eg, succinylcholine) or after manipulation of
the pharynx or trachea. Vagal stimulation causes bradycardia and
hypotension, and in severe cases can result in cardiac arrest.
How Can You Avoid This Medication Error?
Answer: To prevent possible complications, more information must
be obtained from Mr. Miller before the scopolamine patch can be
safely administered. If Mr. Miller has closed-angle glaucoma, ad-
ministering an anticholinergic agent could result in a significant rise
in intraocular pressure and visual impairment. If it cannot be deter-
mined whether Mr. Miller has open-angle or closed-angle glaucoma,
the drug should be held. Anticholinergic medications should be used
cautiously with clients who have BPH because these drugs can
cause urinary retention. Anticholinergic medications increase heart
rate, which may not be advisable for many clients with heart disease.
Review and Application Exercises
1. How do anticholinergic drugs exert their therapeutic effects?
2. What are indications for use and contraindications for
anticholinergic drugs?
3. What is the effect of anticholinergic drugs on heart rate,
and what is the mechanism for this effect?
4. Under what circumstances is it desirable to administer
atropine before surgery, and why?
5. What are adverse effects of anticholinergic drugs?
CHAPTER 21 ANTICHOLINERGIC DRUGS 319
6. What treatment measures are indicated for a client with an
overdose of a drug with anticholinergic effects?
7. Name two other commonly used drug groups that have
anticholinergic effects.
8. What nursing observations and interventions are needed to
increase client safety and comfort during anticholinergic
drug therapy?
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