Risky CNS Drug Use Remains Common in Older Adults
Medicare data show persistent prescribing of high-risk brain-acting medications despite long-standing safety guidelines
A large U.S. analysis shows that potentially inappropriate central nervous system medications remain widely prescribed to older adults, particularly those with cognitive impairment or dementia, even though overall use has modestly declined over the past decade.
Study Details
This study examined real-world prescribing patterns among older Americans to determine whether years of safety warnings have translated into meaningful changes in clinical practice. The focus was on medications known to increase the risk of delirium, falls, hospitalization, and functional decline in seniors, especially those with cognitive impairment.
Investigators analyzed Medicare fee-for-service claims from 2013 through 2021, covering adults aged 65 years and older with normal cognition, cognitive impairment without dementia, or dementia. The work was led by researchers from UCLA David Geffen School of Medicine and funded by the National Institute on Aging.
Methodology
Researchers evaluated whether beneficiaries received at least one potentially inappropriate CNS-active medication for 28 days or longer. Five drug classes were assessed:
Antidepressants with strong anticholinergic properties
Antipsychotics
Barbiturates
Benzodiazepines
Nonbenzodiazepine hypnotics
Analyses adjusted for age, sex, race and ethnicity, comorbidities, socioeconomic status, and cognitive status to isolate prescribing trends over time.
Key Findings
Overall prescribing declined from 19.9 percent in 2013 to 16.2 percent in 2021, a modest but statistically significant reduction.
Benzodiazepine use fell from 11.4 percent to 9.1 percent, while nonbenzodiazepine hypnotic use dropped sharply from 7.4 percent to 2.9 percent.
Prescribing rates for antipsychotics and barbiturates showed no meaningful decline over time.
Patients with cognitive impairment remained at highest risk, with potentially inappropriate prescriptions affecting 21.7 percent of those with cognitive impairment without dementia and 25.1 percent of those with dementia.
In 2021, more than 70 percent of these high-risk prescriptions lacked a documented clinical indication.
Implications for Practice
For patients and families, these findings reinforce the importance of regularly reviewing medication lists, especially when memory problems or confusion are present. Many CNS-active drugs are started during acute illness or stressful periods and then continued indefinitely without reassessment.
For clinicians, the study highlights a clear opportunity to improve medication safety through structured deprescribing, better documentation of indications, and non-pharmacologic approaches to managing insomnia, anxiety, and behavioral symptoms in dementia.
While progress has been made, the persistence of high-risk prescribing suggests that guideline awareness alone is not sufficient. System-level support, time for medication reviews, and caregiver engagement remain critical.