One in Four Older Americans With Dementia Are Still Being Prescribed Risky Brain-Altering Drugs Despite Safety Warnings
For years, doctors and medical organizations have warned against prescribing certain brain-altering medications to older adults with dementia. These drugs are known to increase the risk of falls, confusion, hospitalization, and other serious complications, especially in people whose cognitive function is already impaired. Yet new research shows that these warnings are still not being fully followed.
A large new study published in January 2026 in the Journal of the American Medical Association (JAMA) reveals that about one in four older Americans with dementia enrolled in Medicare are prescribed potentially inappropriate central nervous system (CNS)-active medications. The findings highlight an ongoing gap between clinical guidelines and real-world prescribing practices, raising concerns about medication safety for millions of older adults.
What the Study Looked At
The research team analyzed prescribing patterns over a nine-year period, from January 1, 2013, through December 31, 2021. To do this, they used data from the Health and Retirement Study, a long-running national survey of older adults, and linked it with Medicare fee-for-service claims. This allowed the researchers to track which medications people were prescribed and how those patterns changed over time.
Older adults in the study were divided into three groups:
- Those with normal cognitive function
- Those with cognitive impairment without dementia
- Those with diagnosed dementia
The goal was to see how often potentially inappropriate CNS-active medications were prescribed across these groups and whether prescribing trends improved over time.
Which Medications Were Studied
The study focused on five major classes of CNS-active medications that are widely recognized as risky for older adults, particularly those with cognitive issues. These included:
- Benzodiazepines, commonly prescribed for anxiety and insomnia
- Non-benzodiazepine hypnotics, often used as sleep medications
- Antipsychotic drugs, sometimes prescribed to manage behavioral symptoms
- Antidepressants with strong anticholinergic properties, which can worsen confusion and memory problems
- Barbiturates, an older class of sedative drugs
These medications can interfere with brain function and have been linked to adverse effects such as delirium, dizziness, slowed reaction time, and increased fall risk. Clinical guidelines generally recommend avoiding or minimizing their use in older adults whenever possible.
How Common These Prescriptions Still Are
Despite long-standing safety warnings, the study found that these medications remain surprisingly common, especially among people with cognitive impairment.
- 17% of older adults with normal cognition were prescribed at least one of these CNS-active drugs
- Nearly 22% of older adults with cognitive impairment but no dementia received them
- About 25% of older adults with dementia were prescribed these medications
This pattern shows a troubling trend: the more cognitively vulnerable a person is, the more likely they are to receive medications that can further impair brain function.
Changes in Prescribing Trends Over Time
There was some good news in the findings. Across all Medicare fee-for-service beneficiaries, overall prescribing of potentially inappropriate CNS-active medications declined from about 20% in 2013 to 16% in 2021.
When broken down by medication class, the trends were mixed:
- Benzodiazepine prescriptions declined from 11.4% to 9.1%
- Non-benzodiazepine sleep drugs saw a sharper drop, from 7.4% to 2.9%
- Antipsychotic prescriptions increased, rising from 2.6% to 3.6%
- Anticholinergic antidepressants remained unchanged at 2.6%
- Barbiturate use decreased slightly, from 0.4% to 0.3%
Overall, the decline in prescribing was driven mainly by reduced use of benzodiazepines and sleep medications. However, the rise in antipsychotic use remains a concern, particularly in patients with dementia.
Inappropriate Prescribing Remains a Major Issue
One of the most striking findings was how often these medications were prescribed without a clear clinical justification. By 2021, more than two-thirds of patients receiving these drugs lacked a documented medical reason that aligned with prescribing guidelines.
The study distinguished between clinically justified prescriptions and those considered likely inappropriate. While clinically justified prescribing fell slightly from 6% in 2013 to 5.5% in 2021, inappropriate prescribing dropped more substantially, from 15.7% to 11.4%. Even with this improvement, the remaining level of inappropriate use is still significant.
Why These Medications Are Especially Risky for Dementia Patients
Older adults with dementia are particularly vulnerable to the side effects of CNS-active drugs. Their brains are already struggling with memory, judgment, and processing speed, and medications that further suppress or alter brain activity can make things worse.
Common risks include:
- Increased falls and fractures
- Worsening confusion or delirium
- Higher rates of hospitalization
- Reduced ability to perform daily activities
- Potential acceleration of cognitive decline
Because of these risks, most geriatric and dementia care guidelines recommend non-drug approaches first, such as behavioral strategies, environmental changes, and caregiver support.
What the Study Could Not Capture
Like all research, this study had limitations. It did not include Medicare Advantage enrollees, meaning the findings may not reflect prescribing patterns in that population. Some clinical details, such as agitation or behavioral symptoms, may not have been fully captured in claims data. The analysis also focused on whether a medication was prescribed, rather than how long patients were exposed to it or how many drugs they took simultaneously.
Why This Research Matters
This study underscores a persistent issue in U.S. healthcare: clinical guidelines do not always translate into everyday practice. While progress has been made, millions of older Americans with cognitive impairment are still exposed to medications that may do more harm than good.
The findings highlight the importance of regular medication reviews, especially for older adults with dementia. Patients, caregivers, and healthcare providers all play a role in questioning whether a medication is truly necessary, whether safer alternatives exist, and whether tapering or discontinuation might be possible.
Understanding CNS-Active Medications in Older Adults
CNS-active medications affect how the brain communicates and regulates behavior, mood, sleep, and alertness. In younger adults, these drugs may be relatively well tolerated. In older adults, however, changes in metabolism, brain structure, and drug sensitivity can dramatically increase the risk of side effects.
This is why geriatric prescribing frameworks, such as the Beers Criteria, flag many of these medications as potentially inappropriate for older adults, particularly those with dementia. The goal is not to eliminate their use entirely, but to ensure they are prescribed only when benefits clearly outweigh risks.
The Bigger Picture
As the U.S. population ages and dementia becomes more common, medication safety will remain a critical issue. This study serves as a reminder that progress is possible, but there is still a long way to go. Reducing inappropriate prescribing could improve quality of life, lower healthcare costs, and prevent avoidable harm for millions of older Americans.
Research paper reference:
https://jamanetwork.com/journals/jama/fullarticle/2843713
