Why People with Dementia Still Get Risky Brain‑Active Drugs — And What Families Can Do

Quick summary

Certain brain‑active medicines — anticholinergics, benzodiazepines and some hypnotics, and many antipsychotics — increase confusion, falls and hospitalization risk in older adults, and the risk is higher in people with dementia.
Overall prescribing of these drugs has fallen, but people with cognitive impairment remain more likely to receive them, and many prescriptions lack clear documented reason.
Safer alternatives, structured medication review, and supervised deprescribing can reduce harms. Families and caregivers are key advocates and can prepare for productive conversations with clinicians and pharmacists.

Introduction

Many clinicians and geriatric experts have long warned that some commonly used brain‑active medicines can worsen cognition, increase falls and lead to hospitalization in older adults. That concern is especially urgent for people with dementia. Although prescribing of several high‑risk drug classes has declined, people with cognitive impairment are still more likely to receive them — and in many cases there is no clear, documented clinical reason in the medical record.

This article explains which medicines raise concern, why risky prescribing persists, practical non‑drug and safer medication approaches, how deprescribing typically proceeds, and concrete steps families and caregivers can take to improve safety. It’s written to help you prepare for conversations with clinicians and to support safer care decisions.

Which drugs raise concern — and what they do

Medicines most often implicated include:

Anticholinergics (some bladder remedies, first‑generation antihistamines, and certain antidepressants): can impair memory, attention and balance.
Benzodiazepines and some sedative hypnotics (e.g., diazepam, lorazepam, zolpidem): linked to sedation, slowed reaction time and falls.
Antipsychotics (sometimes used off‑label for agitation or psychosis): increase risk of stroke and mortality in dementia when used long term, and cause sedation and falls.

When these medicines are started without clear indication, continued by default, or prescribed by multiple clinicians without coordination, harms can outweigh benefits — particularly for people who already have cognitive impairment or mobility problems.

Why risky prescribing still happens

Multiple factors contribute:

Symptom pressure: Families understandably want quick relief for agitation, insomnia or urinary problems; clinicians may prescribe to address immediate distress.
Fragmented care: Multiple prescribers and handoffs (hospital, specialist, primary care) can leave medication ownership unclear.
Limited time: Short appointments make comprehensive medication reviews and non‑drug planning harder.
Awareness and systems gaps: Not all clinicians are confident with deprescribing, and electronic records may not flag cumulative anticholinergic or sedative burden.

Safer approaches and non‑drug options

Many behavioral and physical problems can be managed without high‑risk drugs, or with lower‑risk strategies used first. Consider:

Behavioral and environmental interventions for agitation and sleep — consistent routines, adequate daytime activity, light exposure, addressing pain, and identifying unmet needs (hunger, thirst, toileting).
Sleep hygiene and cognitive‑behavioral approaches for insomnia rather than immediate sedative use.
Physical activity and mobility programs to reduce falls and improve mood — tailored exercise often helps more than sedating medicines. (See related guidance on exercise vs therapy for mood here.)
Identify reversible causes — infections, constipation, medication side effects, dehydration, hearing or vision loss can all mimic or worsen behavioral symptoms.
When medicines are needed, choose lower‑risk options and the lowest effective dose with a clear plan for review and stop dates.

Practical lifestyle supports — consistent nutrition, hydration, structured daily activities and social engagement — also reduce symptom burden. For ideas on small habit changes families can try, see this piece on healthy daily choices about hydration and habits.

How to request and prepare for a medication review

Families can prompt meaningful change. Steps to prepare:

Assemble a complete, up‑to‑date medication list (prescription, over‑the‑counter, topical, herbal supplements) with doses and when taken.
Keep a short symptom diary (time of day, triggers, severity) for behaviors, sleep problems or urinary issues — clinicians make better decisions with data.
Ask your primary care clinician or pharmacist for a structured medication review focused on cognitive risk and falls.
If medications were started in hospital or by another specialist, request a reconciliation and clear documentation of the indication and intended duration.

Checklist for a productive medication‑safety conversation

Bring the medication list and the symptom diary to the appointment.
Ask: What is the intended benefit? How long do we plan to try this? What are the specific risks for someone with dementia?
Request alternatives and a stepwise plan: trial non‑drug measures, then lowest‑risk medication if needed; set a time to review.
Clarify monitoring and follow‑up: who will check for withdrawal, side effects, or return of symptoms?
Ask the clinician to document the rationale in the record so future prescribers understand the plan.

How deprescribing typically works (overview)

Deprescribing is a planned, supervised process to reduce or stop medicines where harms may outweigh benefits. Key features:

Shared decision‑making: Clinicians, patients and caregivers weigh goals (safety, quality of life) and prioritize which drugs to stop.
Prioritization: Target medicines with highest risk and lowest current benefit (e.g., anticholinergics, long‑term benzodiazepines, antipsychotics without a clear indication).
Gradual tapering: Many drugs require slow dose reduction to avoid withdrawal or rebound symptoms.
Monitoring and contingency plans: Arrange follow‑up to monitor for adverse effects and a plan to restart or try alternatives if needed.

Never stop or change doses without medical guidance — some medications need careful medical supervision to taper safely.

Common mistakes to avoid

Stopping medications abruptly without clinician oversight — can cause withdrawal or symptom recurrence.
Assuming a long‑used drug is harmless — risk often increases as people age and become frailer.
Forgetting OTC medicines and supplements — many have anticholinergic or sedative effects.
Using medication as the default for behavior or sleep problems without trying environmental or behavioral strategies.
Failing to coordinate among prescribers — poor communication can perpetuate inappropriate treatments.

When to seek urgent help

Contact a clinician or emergency services if the person with dementia experiences sudden severe confusion, new or worsening difficulty breathing, fainting or loss of consciousness, signs of stroke (sudden weakness, slurred speech), or severe withdrawal symptoms after a medication change. If you are unsure, ask the clinician who manages their care what symptoms would warrant urgent contact.

Conclusion

Medication safety in dementia care remains a pressing issue. While prescribing of several risky brain‑active drugs has declined, people with cognitive impairment still face disproportionate exposure, and many prescriptions lack documented justification. Families and caregivers are essential advocates: assembling medication lists, documenting symptoms, requesting structured reviews, and asking specific questions can prompt safer, individualized care. Work with primary care clinicians, pharmacists, and specialists to develop a clear plan that balances symptom control with minimizing harm.

Frequently asked questions (5)

Are all antipsychotics unsafe for people with dementia?
Antipsychotics carry increased risks (sedation, falls, and higher risk of stroke and death in dementia) especially with long‑term use. They may be used in limited situations (e.g., severe psychosis or dangerous agitation) for short trials under specialist supervision with careful monitoring. Always discuss risks, expected benefits and alternatives with the prescriber.
Will stopping sedatives make insomnia or anxiety worse?
Abrupt withdrawal can cause rebound insomnia, anxiety or other symptoms. A planned taper supervised by a clinician, combined with behavioral sleep strategies and non‑drug approaches, is safer and often effective.
How often should medications be reviewed for someone with dementia?
Regular reviews are recommended: typically at least annually, and sooner after hospital discharge, new symptoms, or when new medicines are started. Patients with frailty or multiple interacting drugs may need more frequent checks.
Can over‑the‑counter products be harmful?
Yes — some OTC antihistamines, sleep aids and herbal remedies have anticholinergic or sedative properties that can worsen cognition and increase fall risk. Always include OTC products and supplements when discussing medications with clinicians or pharmacists.
Who should I ask for help if I’m worried about a medication?
Start with the primary care clinician and request a pharmacist medication review. If questions remain, ask for referral to a geriatrician, old age psychiatrist or a memory clinic for specialist input on deprescribing and complex symptom management.

Note: This article is informational and not a substitute for professional medical advice. Always consult qualified healthcare professionals before making medication changes.