One in Four Older Americans with Dementia Prescribed Risky Brain-Altering Drugs

Why It Matters

These prescribing patterns expose vulnerable seniors to preventable adverse events, raising costs and straining the healthcare system while signaling a need for stronger stewardship and policy interventions.

Key Takeaways

• One in four dementia patients receive CNS‑active drugs.
• Inappropriate prescriptions dropped from 15.7% to 11.4%.
• Antipsychotic use rose despite overall prescribing decline.
• Only 5.5% of prescriptions were clinically justified in 2021.
• Guidelines advise against these drugs for cognitively impaired seniors.

Pulse Analysis

The prevalence of potentially inappropriate central nervous system (CNS)‑active medications among older adults has long been a red flag for clinicians and policymakers. Guidelines from the American Geriatrics Society and the FDA caution against anticholinergic antidepressants, benzodiazepines, and similar agents in patients with cognitive impairment because they amplify risks of falls, delirium, and hospital readmissions. Yet the new JAMA analysis shows that a quarter of Medicare beneficiaries with dementia still receive these high‑risk drugs, underscoring a persistent gap between evidence‑based recommendations and real‑world practice.

The study tracked prescribing trends from 2013 to 2021 using linked Health and Retirement Study data and Medicare fee‑for‑service claims. Overall CNS‑active medication use among seniors dropped from 20% to 16%, driven largely by declines in benzodiazepine prescriptions (down to 9.1%) and non‑benzodiazepine hypnotics (down to 2.9%). However, antipsychotic prescribing rose from 2.6% to 3.6%, and the proportion of potentially inappropriate prescriptions fell only modestly, from 15.7% to 11.4%. Notably, just 5.5% of prescriptions in 2021 were tied to a documented clinical indication, highlighting extensive off‑label use, especially among those with dementia (25% prevalence) compared with cognitively normal peers (17%).

These findings carry clear implications for health systems and regulators. Reducing inappropriate CNS‑active drug use could lower fall‑related injuries, curb unnecessary hospital stays, and generate cost savings for Medicare. Interventions may include electronic prescribing alerts, pharmacist‑led medication reviews, and targeted education for prescribers and caregivers. Moreover, the rise in antipsychotic use suggests a need to explore alternative behavioral and non‑pharmacologic strategies for managing neuropsychiatric symptoms in dementia. Ongoing surveillance and inclusion of Medicare Advantage data will be essential to fully capture prescribing patterns and drive quality‑improvement initiatives.