Five drug groups carry warnings for older adults, yet prescribing remains highest among those with dementia.
One in four older Americans with dementia is prescribed potentially inappropriate medicines that affect the brain and nervous system.
These drugs can increase the risk of confusion, falls and hospitalisation, particularly in people whose thinking and memory are already impaired.
Despite decades of warnings, people with cognitive impairment were more likely to receive these prescriptions than those with normal cognition.
Five drug groups
The research examined five categories of medication flagged by prescribing guidelines for older adults:
- Antidepressants with strong anticholinergic effects.
- Antipsychotics.
- Barbiturates.
- Benzodiazepines.
- Nonbenzodiazepine sleeping medicines, sometimes called Z-drugs.
Only antidepressants with strong anticholinergic properties were included in this category.
Anticholinergic medicines block acetylcholine, a chemical messenger involved in memory, learning and concentration.
Blocking its action can cause confusion and other unwanted effects, especially in older adults.
Benzodiazepines, which may be prescribed for anxiety or sleep problems, can cause excessive drowsiness and increase the risk of falls.
Some medicines also take longer to leave the body as people age, allowing their effects to persist or accumulate.
Who receives them?
The researchers analysed survey information linked to medical insurance records from almost 4,900 Americans aged 65 and over.
They examined prescribing over nine years, counting prescriptions for at least four weeks’ supply.
Around 17 percent of people with normal cognition received at least one potentially inappropriate prescription, compared with almost 22 percent of those with cognitive impairment without dementia.
Among people with dementia, the proportion reached 25 percent.
Some encouraging changes
Across the older adults studied, prescribing fell from around 20 percent at the beginning of the study period to 16 percent at the end.
Much of the decline reflected fewer prescriptions for benzodiazepines and Z-drug sleeping medicines.
However, prescribing rates for the other three drug groups did not change significantly.
By the final year, more than two-thirds of people receiving these potentially inappropriate prescriptions lacked a documented clinical reason for at least one of them.
When benefits outweigh risks
A potentially inappropriate medicine can still be justified when its expected benefits outweigh its risks.
The practical question is whether each prescription remains suitable for the person taking it.
Dr Annie Yang, the study’s first author, emphasised the importance of patients and carers reviewing these medicines with their physicians:
“While CNS-active prescriptions may be appropriate in some cases, it is important for older patients or their caregivers to work closely with their physicians to ensure that these medications are appropriate to their cases.
When inappropriate, patients and their care teams should consider alternative treatments and consider whether it might be safe to taper or stop the medication.”
The study was published in JAMA (Yang et al., 2026).
