Anticholinergic

One in four Medicare beneficiaries with dementia received risky CNS drugs, despite long-standing caution

New peer‑reviewed research published January 12 in JAMA finds that potentially inappropriate central nervous system (CNS)-active medications remain common in older adults with cognitive impairment. While overall prescribing of these drugs declined over nine years among Medicare beneficiaries, use remained highest in people living with dementia-patients who face heightened risks of falls, confusion, and hospitalization.

“While this decline was encouraging, over two-thirds of patients receiving these prescriptions lacked a documented clinical indication in 2021, the end of the study period, suggesting high levels of potentially inappropriate and harmful prescribing,” said senior author Dr. John N. Mafi, associate professor-in-residence of medicine, division of general internal medicine and health services research, at the David Geffen School of Medicine at UCLA. “Compared with patients with normal cognition, we also found higher levels of prescribing among older adults with cognitive impairment, who face a higher risk of adverse effects from these drugs. These results underscore substantial opportunities to improve the quality and safety of care for millions of older Americans.”

The findings land squarely in the middle of ongoing federal efforts to make prescribing to older adults safer. Medicare is overseen by the Centers for Medicare & Medicaid Services (CMS) under the Social Security Act, and CMS already uses quality measures tied to payment to discourage high-risk drug use in nursing homes. The new data suggest similar scrutiny may now be needed in community and outpatient settings, where most older adults with dementia receive care.

What the study measured

The analysis linked Medicare claims to detailed cognitive assessments in the long‑running Health and Retirement Study, allowing researchers to examine prescribing patterns by cognitive status rather than relying solely on diagnosis codes.

• Population: Medicare fee‑for‑service beneficiaries participating in the Health and Retirement Study.
• Period: January 1, 2013-December 31, 2021, spanning major federal initiatives on opioid and sedative safety.
• Groups assessed: normal cognition; cognitive impairment without dementia; dementia.
• Drug classes: antidepressants with strong anticholinergic properties; antipsychotics; barbiturates; benzodiazepines; non‑benzodiazepine hypnotics.

How common was use by cognitive status

Across the full study period, older adults with any degree of cognitive impairment were consistently more likely to receive CNS‑active prescriptions than their cognitively normal peers.

Overall trend among Medicare fee‑for‑service enrollees

At the population level, use of these drugs moved in the right direction but remained high, and most of the decline came from prescriptions without clear justification in claims.

• Any CNS‑active prescription: decreased from 20% (2013) to 16% (2021).
• Clinically justified prescriptions: 6.0% (2013) to 5.5% (2021).
• Likely inappropriate prescriptions: 15.7% (2013) to 11.4% (2021).

Class‑by‑class shifts from 2013 to 2021

Patterns varied markedly by drug class, reflecting both evolving clinical guidance and shifts in payer and regulatory focus.

Appropriateness and documentation gaps

The study did not simply count prescriptions; it tested whether claims reflected a plausible medical reason for exposure.

• At the close of the study period in 2021, more than two‑thirds of beneficiaries with CNS‑active prescriptions did not have a documented clinical indication in claims data.
• Reductions in use were driven largely by fewer benzodiazepine and sleep‑medication prescriptions, alongside declines in likely inappropriate use.
• The absence of a recorded indication does not prove misuse, but it sharply limits the ability of Medicare, regulators, and health plans to distinguish high‑value prescribing from avoidable risk.

Why this remains a patient‑safety issue

The results sit against a longstanding backdrop of geriatric prescribing guidance and federal warnings on CNS‑active drugs in dementia.

• Older adults-especially those with cognitive impairment-are more vulnerable to CNS drug-related harms, including falls, delirium, and worsened cognition.
• Antipsychotics carry a boxed warning for increased mortality in older adults with dementia‑related psychosis, underscoring the importance of careful risk-benefit assessment.
• The American Geriatrics Society’s Beers Criteria identifies benzodiazepines, strong anticholinergics, and certain sedative‑hypnotics as potentially inappropriate for many older adults.

Existing guardrails and where they fall short

Regulators and payers have already deployed some tools, but the protections are uneven-and often weaker where most dementia care actually occurs.

• Long‑term care settings track antipsychotic exposure through federal quality measures linked to facilities’ oversight and payment, yet comparable, consistently applied accountability in outpatient settings is less developed.
• Coverage and benefit design can unintentionally favor low‑cost sedatives over non‑pharmacologic supports (e.g., caregiver training, behavioral therapies) that reduce agitation and insomnia in dementia but require time and workforce capacity.
• E‑prescribing systems include clinical decision support; however, indication capture is not uniformly required in claims, limiting the ability to distinguish justified use from potentially inappropriate prescribing and to enforce safety‑oriented coverage policies.

Policy levers that could reduce avoidable exposure

For policymakers, the findings highlight a concrete set of levers within existing Medicare and regulatory authority. Under Title XVIII of the Social Security Act, CMS can use quality programs, payment rules, and plan requirements to shape how these medications are used.

• Quality measurement: Extend outpatient measures that flag high‑risk CNS combinations and anticholinergic burden in older adults with cognitive impairment, and consider tying performance more directly to value‑based payment.
• Payment and benefits: Align Medicare Part D and Medicare Advantage formularies and prior authorization with deprescribing goals; reimburse non‑pharmacologic dementia care supports that can avert sedative use.
• Documentation standards: Require an indication field for CNS‑active prescriptions in electronic prescribing and pharmacy claims to strengthen auditability and safety surveillance.
• Pharmacy services: Expand pharmacist‑led comprehensive medication reviews for beneficiaries with cognitive impairment, with structured feedback loops to prescribers.
• Workforce and training: Scale dementia‑capable primary care and geriatric consultation capacity to manage behavioral symptoms without reflexive reliance on sedatives.

Equity and access considerations

The burden of inappropriate CNS use is unlikely to be evenly distributed. Structural gaps in the U.S. health system can steer certain communities toward higher‑risk pharmacologic choices.

• Gaps in access to geriatric and behavioral health specialists can drive reliance on pharmacologic shortcuts, particularly in rural or under‑resourced communities.
• Caregiver availability and health‑system navigation barriers can influence treatment choices, with disproportionate effects on low‑income and minoritized older adults.
• Policy changes that improve reimbursement for non‑drug dementia care and that support family caregivers-such as navigation services and respite-may therefore function as safety interventions as much as equity measures.

What the authors say about next steps

“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,” said Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University who led this study as a UCLA internal medicine resident.

The authors add that health systems and payers can support safer use by embedding deprescribing protocols, building dementia‑specific consult services, and ensuring that coverage rules do not make the safest options the hardest to access.

Study caveats to keep in mind

As with all claims‑based work, the analysis has important limits that matter for policymakers and clinicians interpreting the numbers.

• Data do not include Medicare Advantage beneficiaries, who now represent a growing share of enrollees.
• Claims may lack clinical details-such as severity of agitation-that influence prescribing decisions.
• Prevalence snapshots do not capture cumulative exposure or dose intensity over time.

By the numbers: key datapoints at a glance

Funding and collaborators

The study was funded by the National Institutes of Health/National Institute on Aging (R01AG070017-01) and conducted by a team spanning academic and federal care systems, including UCLA, RAND, the University of Michigan, and the VA Greater Los Angeles Healthcare System. Together, they argue that the next phase of CNS‑safety policy will need to move beyond counting prescriptions to closing the structural gaps that keep inappropriate use so persistent.