If you live with an overactive bladder (OAB), you probably plan your day around bathrooms: where they are, how fast you can get there, and whether you’ll make it in time. Now add a new worry: you’ve heard that some bladder medications might increase your dementia risk. Are you supposed to choose between your bladder and your brain?
You shouldn’t have to.
This guide explains how common OAB medications work, what we know about anticholinergic “burden” and dementia, and how newer options like mirabegron (Myrbetriq) differ.
Overactive Bladder Is Common – But Not Part of ‘Normal Aging’
Many people assume that leaking or “can’t-hold-it” urgency is just what happens with age. The science says otherwise.
Overactive bladder is defined by the International Continence Society (ICS) as:
Urinary urgency (a sudden, hard-to-ignore need to pee), usually with frequency (going many times a day) or nocturia (waking at night to pee), with or without urge incontinence (leaks), and no obvious cause like a urinary infection.
While about one in six adults has an overactive bladder, this number rises as age increases. A recent study found that overactive bladder affects about 36% of adults aged 40 and older, with women experiencing overactive bladder more frequently than men (41% to 31%, respectively). This indicates that although overactive bladder is common after age 39, it is neither common nor inevitable with age.
What’s more, an overactive bladder is treatable.
The complicating factor is that some medications for an overactive bladder are known to pose risks to your brain. This isn’t equally true of all options, however.
The Hidden Side of Bladder Drugs: Anticholinergic Burden
Many long-time OAB medications are antimuscarinic (anticholinergic) drugs. All of them work by blocking muscarinic acetylcholine receptors in the bladder muscle, so it doesn’t contract as often or as forcefully. That calms urgency and leaks.
These antimuscarinic OAB medications include:
• Oxybutynin (Ditropan, Oxytrol patch)
• Tolterodine (Detrol, Detrol LA)
• Solifenacin (Vesicare)
• Darifenacin (Enablex)
• Trospium (Sanctura)
• Fesoterodine (Toviaz)
But acetylcholine isn’t just in your bladder. It’s also one of the major neurotransmitters your brain uses for attention, learning, and memory. The same receptor blockade that helps your bladder can, in some people, affect thinking—especially if:
• The dose is high
• Treatment is long-term
• The drug crosses the blood-brain barrier easily
• The person is older or already has some cognitive vulnerability
This means that not everyone is at the same risk when taking an individual medication. No medication is universally good or bad. Each person has their own risk vs. reward equation.
(More about how drugs with anticholinergic effects affect cognition, here.)
Anticholinergic Burden: Why Your Whole Pill List Matters
Doctors look at a patient’s complete anticholinergic burden, which is the total anticholinergic effect from all the medications you’re taking, not just your bladder pill.
In addition to OAB antimuscarinics, strong anticholinergic effects show up in:
• Some antidepressants
• Older antihistamines (used for allergies or sleep)
• Certain anti-nausea, dizziness, or irritable bowel drugs
Large epidemiologic studies and geriatric reviews have repeatedly linked higher cumulative anticholinergic exposure with worse cognitive outcomes and a higher risk of dementia in older adults.
This is why many geriatric and neurology teams now actively try to reduce anticholinergic burden in people over 65 whenever there’s a reasonable alternative.
What the Science Actually Says: OAB Drugs and Dementia Risk
You’ve probably seen headlines about overactive bladder drugs increasing dementia risk, and that can be scary. Let’s take a look at what four major studies really show.
1. Strong anticholinergics and dementia (all causes)
A 2019 major nested case-control study in the Journal of the American Medical Association (JAMA) Internal Medicine looked at over 58,000 people with dementia and 225,000 matched controls ages 55 and older in the UK.
• Cumulative exposure to strong anticholinergic medications over the previous 4–20 years was associated with a higher risk of dementia.
• Bladder antimuscarinics were one of the drug classes most strongly linked to this increased risk.
This doesn’t prove that the drugs cause dementia (observable data shows correlation, not causation), but the size and design of the study make the association hard to ignore.
2. Overactive bladder anticholinergics specifically
Several studies have looked at overactive bladder anticholinergics, specifically, and they have confirmed findings similar to this 2024 nested case-control study of over 170,000 older adults with dementia in England, compared with about 800,000 controls, which looked specifically at anticholinergic drugs for overactive bladder.
Compared with no use:
• Every anticholinergic OAB medication class was associated with higher dementia rates.
• The strongest signals were for oxybutynin, solifenacin (Vesicare), and tolterodine (Detrol/Detrol LA).
Again, this is an association, not proof of causation. However, multiple studies have now reported the same result across different research teams and datasets, indicating a pattern worth attention.
3. Anticholinergics vs. β3 agonists (like mirabegron)
More recently, researchers have asked a smart follow-up: What happens when we compare OAB patients on anticholinergics with those on a non-anticholinergic option such as mirabegron (Myrbetriq)?
• A population-based cohort study from Ontario, Canada, compared patients with OAB starting on an anticholinergic vs. those starting on a β3 agonist (mirabegron).
• Result: people on anticholinergic OAB meds had about a 23% higher risk of developing dementia than those on mirabegron (hazard ratio 1.23, 95% CI 1.12–1.35).
These results line up with other international data suggesting β3 agonists carry a lower dementia risk than anticholinergic OAB drugs in older adults.
4. Oxybutynin: the “usual suspect.”
However, it’s important to note that not all OAB anticholinergics affect the brain the same way. Multiple randomized trials and reviews have flagged oxybutynin as particularly problematic for cognition in older adults:
• A British Medical Journal (BMJ) analysis noted that anticholinergic urological drugs, especially oxybutynin, have been “consistently associated with short-term cognitive decline, so a long-term risk of dementia is plausible” in randomized trials.
This is unfortunate, as oxybutynin is still very commonly prescribed for OAB.
Are Any Antimuscarinics “Kinder” to the Brain?
This is where nuance matters, as not all antimuscarinics are the same. For example,
• Trospium (Sanctura) is more water-soluble and less likely to cross the blood–brain barrier passively (it’s a quaternary ammonium compound). Animal and human data show low levels (or none) in cerebrospinal fluid and no clear memory deterioration signal over the short term in older adults.
• Darifenacin (Enablex) appears to have a more favorable cognitive profile than oxybutynin in some small comparative studies (as it is more selective for the M3 receptor subtype, which is important in the bladder), though evidence is limited.
That said, while trospium or darifenacin may be relatively lower-risk choices within the anticholinergic family, they have their own trade-offs and do contribute to a person’s anticholinergic burden overall.
Mirabegron (Myrbetriq): Bladder Control Without Anticholinergic Load
If you’re concerned about your anticholinergic load, mirabegron (Myrbetriq) may be an option to consider. This is because mirabegron isn’t an anticholinergic. It’s a β3-adrenergic receptor agonist. This means that instead of blocking muscarinic acetylcholine receptors in the bladder muscle, it activates the β3 receptors that live on the detrusor muscle of your bladder. When mirabegron activates β3 receptors, the bladder muscle relaxes during the storage phase, allowing it to hold more urine with fewer urgency signals. Importantly, it doesn’t work by blocking acetylcholine, so it doesn’t add to a person’s anticholinergic burden.
That different pathway is the whole reason mirabegron is so interesting for people worried about both bladder symptoms and brain health.
The PILLAR study, a phase 4, randomized, placebo-controlled trial, specifically looked at cognition in older adults with OAB on mirabegron. It found that mirabegron did not worsen cognitive function compared with placebo.
Keep in mind, though, all medications still have risks, and so does mirabegron. The main side effects of mirabegron include:
• Tachycardia
• Urinary tract infections
Large trials and pooled analyses show that mirabegron improves OAB symptoms compared with placebo, with a generally acceptable safety profile in adults and older adults.
Final Thoughts: You Deserve Bladder Control and Brain Protection
Overactive bladder steals sleep, spontaneity, and confidence. However, dementia is one of the scariest diagnoses people fear as they age, so it’s completely reasonable to be wary of medication that may increase its risk.
The science is evolving, but right now it suggests:
• Long-term use of strong OAB anticholinergics—especially oxybutynin, solifenacin, and tolterodine—is consistently associated with higher dementia risk in older adults and can impair cognition in the short term.
• Mirabegron (Myrbetriq) offers bladder control through a different pathway (β3 receptors) and, so far, shows no negative cognitive side effects in randomized trials and a lower dementia risk in cohort studies compared with anticholinergic OAB meds.
• Within the anticholinergic family, drugs like trospium and darifenacin may have somewhat more favorable risk profiles. However, they’re still part of your overall anticholinergic burden and need to be weighed with care.
In short, you don’t have to pick between living chained to the bathroom and gambling with your memory. With the right information, you and your clinician can choose an overactive bladder treatment plan that respects both your bladder and your brain.
Sources
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