Some patients genuinely do better off certain medications because the side effects, drug interactions, and cognitive burden of treatment can outweigh the benefits — particularly in older adults living with dementia or multiple chronic conditions. This is not a fringe opinion. Geriatricians and palliative care specialists have long recognized that deprescribing, the careful and supervised process of tapering or stopping medications, can lead to improved alertness, fewer falls, better appetite, and a measurably higher quality of life. Consider an 82-year-old woman with moderate Alzheimer’s disease who was taking a statin, a blood pressure pill, a sleeping aid, and a cholinesterase inhibitor. After her geriatrician gradually discontinued the statin and the sleep medication, her family reported she was more awake during the day, eating better, and engaging more in conversation.
Her underlying disease had not changed, but removing medications that were no longer serving her shifted the balance toward comfort and function. This does not mean medication is the enemy, and nothing in this article should be taken as advice to stop any drug without medical supervision. But the reality is that many patients — especially those over 75, those on five or more medications, and those with advanced dementia — are overtreated according to guidelines designed for younger, healthier populations. The result is a phenomenon sometimes called the prescribing cascade, where one drug causes a side effect that gets treated with another drug, which causes its own problems. This article examines why some patients improve when medications are removed, which drugs are most commonly implicated, how deprescribing works in practice, what the risks are, and when staying on medication is clearly the better choice.
Table of Contents
- Why Do Some Patients Actually Improve When Medications Are Stopped?
- Which Medications Are Most Commonly Stopped in Dementia Patients?
- The Prescribing Cascade and How It Traps Patients
- How Deprescribing Works in Practice
- When Stopping Medication Goes Wrong
- The Role of Goals-of-Care Conversations
- Where the Evidence Is Heading
- Conclusion
- Frequently Asked Questions
Why Do Some Patients Actually Improve When Medications Are Stopped?
The simplest explanation is that every medication carries a cost-benefit ratio, and that ratio shifts as a person ages, becomes frailer, or develops cognitive impairment. A blood pressure medication that prevents a stroke in a healthy 60-year-old may cause dizziness and dangerous falls in an 85-year-old with dementia. A statin prescribed to reduce long-term cardiovascular risk may offer little meaningful benefit to someone whose life expectancy is measured in months or a few years, while its side effects — muscle pain, fatigue, digestive problems — are felt every day. The drug has not changed, but the patient has, and the calculus no longer adds up. There is also the issue of anticholinergic burden. Many common medications, including certain antihistamines, bladder drugs, tricyclic antidepressants, and some sleep aids, block acetylcholine, a neurotransmitter already depleted in Alzheimer’s disease. Prescribing an anticholinergic drug to someone simultaneously taking a cholinesterase inhibitor like donepezil is, pharmacologically speaking, pressing the gas and the brake at the same time.
Research published in journals such as JAMA Internal Medicine has linked high anticholinergic burden to increased confusion, faster cognitive decline, and higher mortality in older adults. When these medications are removed, some patients experience a noticeable cognitive improvement — not because their dementia has reversed, but because a chemical fog has lifted. A third factor is the sheer complexity of managing multiple drugs. Polypharmacy, generally defined as taking five or more medications, increases the risk of adverse drug interactions exponentially. The liver and kidneys, which metabolize and clear these drugs, work less efficiently with age. Doses that were safe at 65 may accumulate to toxic levels at 85. For a patient with dementia who cannot reliably report symptoms like nausea, dizziness, or confusion, these adverse effects may be mistaken for disease progression rather than recognized as medication side effects.
Which Medications Are Most Commonly Stopped in Dementia Patients?
The drugs most frequently targeted for deprescribing in older adults with dementia fall into several categories. Sedatives and sleep medications, particularly benzodiazepines like lorazepam and so-called Z-drugs like zolpidem, are near the top of every geriatrician’s list. These drugs increase fall risk, worsen confusion, and have been associated in some epidemiological studies with accelerated cognitive decline. Their benefit for sleep often diminishes with long-term use as tolerance develops, leaving the patient dependent on a drug that is no longer helping them sleep but is still impairing their balance and cognition. Statins are another common candidate, particularly in patients with advanced dementia or limited life expectancy. While statins are well-established for cardiovascular prevention, their benefit accrues over years. For a patient who is unlikely to live long enough to realize that benefit, the daily cost of side effects like muscle weakness and fatigue may not be justified. Proton pump inhibitors, prescribed for acid reflux, are also frequently reconsidered.
Originally intended for short-term use, many patients remain on them for years, despite evidence linking long-term PPI use to increased fracture risk, kidney problems, and possibly higher dementia risk, though that last association remains debated. However, not every medication is a candidate for removal. Stopping certain drugs abruptly can be dangerous. Beta-blockers, for instance, should never be discontinued suddenly because of rebound hypertension and cardiac risks. Antiepileptic medications, antidepressants, and corticosteroids all require careful, gradual tapering. The decision to deprescribe must also account for what the medication is preventing. If a patient with atrial fibrillation is on a blood thinner, the risk of stroke from stopping it may far exceed any side-effect burden. Deprescribing is not about removing all medications — it is about removing the wrong ones.
The Prescribing Cascade and How It Traps Patients
The prescribing cascade is one of the most underappreciated problems in medicine for older adults. It works like this: a patient takes a medication that causes a side effect, but instead of recognizing the side effect as drug-related, a clinician interprets it as a new condition and prescribes another drug to treat it. That second drug may cause its own side effects, leading to a third prescription, and so on. A real-world example seen commonly in geriatric practice involves a calcium channel blocker prescribed for high blood pressure. The drug causes ankle swelling. The swelling is treated with a diuretic. The diuretic causes low potassium.
The low potassium is treated with a supplement that upsets the stomach. An antacid is added. What started as one medication has become four, each treating a problem created by the one before it. In patients with dementia, the cascade is especially insidious because the patient may not be able to articulate that something changed after starting a new drug. A cholinesterase inhibitor like donepezil commonly causes nausea and diarrhea. If those gastrointestinal symptoms are treated with an anticholinergic anti-nausea drug, the cognitive benefit of donepezil may be partially or fully negated. The patient appears to decline, the family is told the disease is progressing, and no one connects the dots back to the medication interaction. Unraveling a prescribing cascade requires a clinician willing to look at the full medication list with fresh eyes and ask, for each drug, whether the problem it treats might actually be caused by another drug on the list.
How Deprescribing Works in Practice
Deprescribing is not simply stopping medications. It is a structured clinical process that involves reviewing all current medications, identifying those that may no longer be appropriate, prioritizing which to address first, tapering gradually, and monitoring the patient closely for withdrawal effects or return of the original condition. Several evidence-based frameworks exist to guide this process. The Beers Criteria, maintained by the American Geriatrics Society, lists medications that are potentially inappropriate for older adults. The STOPP/START criteria, developed in Europe, offer similar guidance. Deprescribing algorithms for specific drug classes, such as proton pump inhibitors or benzodiazepines, have been published and are freely available through resources like deprescribing.org. The process typically begins with a comprehensive medication review, ideally involving a pharmacist, the prescribing physician, the patient if they are able to participate, and their family or caregiver. Each medication is evaluated against its original indication, current relevance, side-effect profile, and the patient’s goals of care.
For a patient with advanced dementia whose family has prioritized comfort, the threshold for continuing a preventive medication is very different from that of a cognitively intact person focused on longevity. The tradeoff is explicit: deprescribing accepts a theoretical increase in long-term risk in exchange for a concrete improvement in daily quality of life. For some patients and families, that is exactly the right bargain. For others, particularly those in earlier stages of disease with longer life expectancy, the calculation may favor continuing treatment. One important practical consideration is that deprescribing takes time and follow-up. Drugs should generally be stopped one at a time so that if a problem arises, the cause is clear. Tapering schedules vary by drug class — benzodiazepines, for example, may need to be reduced over weeks or months to avoid withdrawal seizures. Caregivers need to know what to watch for and when to call the doctor. This is not a set-it-and-forget-it intervention.
When Stopping Medication Goes Wrong
Deprescribing has real risks, and pretending otherwise does a disservice to patients and families. The most obvious risk is that the condition the medication was treating returns. Stop a blood pressure drug and blood pressure may rise. Stop an antidepressant and depression may relapse. Stop an anticoagulant and the risk of stroke increases. These are not hypothetical dangers — they are predictable consequences that must be weighed against the benefits of stopping. There are also withdrawal syndromes to consider.
Benzodiazepine withdrawal can cause anxiety, insomnia, tremors, and in severe cases, seizures. SSRI antidepressants can cause discontinuation syndrome — dizziness, irritability, flu-like symptoms, and electric shock sensations — even when tapered. Proton pump inhibitors can cause rebound acid hypersecretion, making heartburn temporarily worse than it was before the drug was ever started. These withdrawal effects can be misinterpreted as proof that the patient needs the medication, when in reality they are transient effects of stopping it. A critical warning: deprescribing should never be done without medical supervision, and it should never be driven by cost-cutting or caregiver convenience alone. The goal is always the patient’s wellbeing. Families who read about deprescribing and independently stop a loved one’s medications without consulting their doctor risk serious harm. The value of deprescribing lies in its thoughtfulness — it is the opposite of simply throwing away pill bottles.
The Role of Goals-of-Care Conversations
Deprescribing works best when it is embedded in a broader conversation about what the patient and family actually want from medical care. For someone with early-stage cognitive impairment who is otherwise healthy, aggressive treatment of blood pressure, cholesterol, and diabetes may be entirely appropriate because those interventions protect the brain and body for years to come. For someone with advanced dementia who is bedbound and no longer recognizing family members, the priorities usually shift toward comfort, dignity, and freedom from unnecessary medical burden.
These conversations are not easy, and they are not one-time events. Goals of care evolve as the disease progresses. A family that wanted everything done at diagnosis may feel differently two years later when their loved one is in distress from medication side effects. Clinicians who proactively revisit these conversations — rather than waiting for a crisis — create space for deprescribing to happen thoughtfully rather than reactively.
Where the Evidence Is Heading
Research into deprescribing has accelerated in recent years, with multiple randomized controlled trials and large observational studies attempting to quantify its benefits and risks. As of recent reports, the evidence is strongest for deprescribing sedatives and hypnotics in older adults, where the harms are well-documented and the benefits of stopping are often rapid and visible. The evidence for stopping statins, antihypertensives, and cholinesterase inhibitors in advanced dementia is growing but still incomplete — many studies are small, short-term, or observational.
What seems clear is that the medical community is moving away from a one-size-fits-all approach to prescribing and toward a model that accounts for individual patient context, life expectancy, functional status, and personal values. This shift is overdue. The default in medicine has long been to add treatments and rarely subtract them. Deprescribing challenges that default, and for many patients — particularly those living with dementia — it represents not a withdrawal of care but a more honest and humane form of it.
Conclusion
The idea that some patients do better off medication than on it is not radical or anti-medicine. It is a recognition that drugs are tools with specific purposes, and that those purposes must be re-evaluated as patients age, develop new conditions, and approach the end of life. For people living with dementia, the stakes are especially high because the medications most likely to cause harm — sedatives, anticholinergics, drugs with narrow therapeutic windows — are also the ones most commonly prescribed to this population. Deprescribing, done carefully and collaboratively, can reduce side effects, improve alertness and engagement, lower fall risk, and restore a measure of quality of life that had been quietly eroded by overtreatment.
The most important step any family can take is to request a comprehensive medication review with their loved one’s physician or a geriatric pharmacist. Bring the full list of medications, including over-the-counter drugs and supplements. Ask about each one: what is it for, is it still necessary, and what would happen if we stopped it? These questions are not confrontational — they are exactly the kind of questions good doctors want to hear. The goal is not to eliminate all medication but to find the right medications at the right doses for the person your loved one is today, not the person they were when those prescriptions were first written.
Frequently Asked Questions
Is it safe to stop dementia medications like donepezil or memantine?
It can be, but it must be done gradually and under medical supervision. Some studies suggest that stopping cholinesterase inhibitors in advanced dementia does not worsen outcomes, while others have found a temporary decline after discontinuation. The decision depends on the stage of disease, the patient’s response to the drug, and the family’s goals of care.
How do I bring up deprescribing with my loved one’s doctor without sounding like I want to give up on them?
Frame it as wanting to optimize care, not withdraw it. You might say, “We want to make sure every medication is still helping and not causing unnecessary side effects.” Most geriatricians and palliative care specialists are receptive to this conversation. If your doctor is dismissive, consider requesting a referral to a geriatric specialist.
Will insurance or Medicare cover a medication review specifically for deprescribing?
Medicare covers annual wellness visits that can include medication reviews, and many Medicare Part D plans include medication therapy management programs for patients taking multiple drugs. A geriatric pharmacist consultation may or may not be covered depending on the plan. Check with your specific insurer for details, as coverage varies.
What if my loved one gets worse after stopping a medication?
This is exactly why deprescribing is done one drug at a time with close monitoring. If a condition worsens after stopping a medication, the drug can usually be restarted. Deprescribing is not irreversible. The key is to have a plan in place before stopping and to know what signs to watch for.
Are there medications that should almost never be stopped in elderly patients?
Thyroid replacement hormone, anti-seizure medications in patients with epilepsy, and certain cardiac drugs like anticoagulants for atrial fibrillation generally should not be stopped without very strong justification. Parkinson’s disease medications should also be continued because abrupt withdrawal can cause a dangerous condition called neuroleptic malignant-like syndrome.
