Several common drug classes can worsen thinking, memory, and behavior in people with dementia, and the most important to review with a pharmacist are anticholinergics, benzodiazepines, "Z-drug" sleep aids, and antipsychotics. Many of these are sold over the counter or prescribed for unrelated problems, so the risk often hides in plain sight. A pharmacist can review every prescription, over-the-counter product, and supplement together to spot these culprits and suggest safer options. The goal is not to stop needed treatment on your own, but to bring an informed list to a professional who can weigh benefits against cognitive harm.
Medical information disclaimer: This article is for general educational purposes only and does not provide medical advice, diagnosis, or treatment. Always consult a physician or other qualified health professional about symptoms, medications, tests, or treatment decisions.
Table of Contents
- Anticholinergic drugs: the biggest hidden risk
- Sedatives and sleep aids: benzodiazepines and Z-drugs
- Antipsychotics: a boxed warning to know
- How to prepare for a pharmacist medication review
- Why these reviews matter so often
- Frequently Asked Questions
Anticholinergic drugs: the biggest hidden risk
Anticholinergic drugs block acetylcholine, a brain chemical central to memory and learning. Because dementia already lowers acetylcholine, these drugs can deepen confusion, and the National Institute on Aging reports that cumulative use is linked to higher dementia risk in a dose-dependent way. Roughly 100 such drugs are in wide use, many sold without a prescription. The strength of the evidence is notable.
A large study in JAMA Internal Medicine found the highest cumulative exposure was tied to about 1.5 times higher odds of dementia (adjusted odds ratio 1.49). Even among cognitively healthy older adults, the American Academy of Neurology reported a roughly 47% higher chance of developing mild cognitive impairment over about ten years. Common culprits are easy to overlook. They include sedating antihistamines such as diphenhydramine (Benadryl), overactive-bladder drugs such as oxybutynin, and older tricyclic antidepressants. Many appear in nighttime pain relievers and sleep aids labeled "PM.".
Sedatives and sleep aids: benzodiazepines and Z-drugs
Benzodiazepines, such as lorazepam and diazepam, calm anxiety and agitation but blunt alertness and coordination. In older adults with cognitive impairment, they worsen memory and raise the risk of falls and fractures. The American Geriatrics Society Beers Criteria advises avoiding them in this group.
"Z-drug" hypnotics — zolpidem (Ambien), eszopiclone, and zaleplon — are marketed as gentler sleep aids but carry similar concerns. The same Beers Criteria lists them among medications to avoid in people with dementia because of adverse effects on the central nervous system. Sleep and agitation are real problems for families, so stopping these drugs is rarely simple. That is exactly why a pharmacist review matters: safer routines, timing changes, or alternative treatments may reduce the need for a sedative without a sudden, unsafe withdrawal.
Antipsychotics: a boxed warning to know
Antipsychotics such as quetiapine (Seroquel) and risperidone are sometimes used for agitation, aggression, or hallucinations in dementia. They carry the strongest formal caution: the FDA requires a Boxed Warning on all antipsychotics about increased death in elderly patients with dementia-related psychosis, and they are not approved for that use. The numbers behind the warning are concrete.
Across 17 placebo-controlled dementia trials of about ten weeks, FDA labeling analysis found death rates of roughly 4.5% on antipsychotics versus 2.6% on placebo — about 1.6 to 1.7 times higher — mostly from cardiovascular events or infections. This does not mean these drugs are never appropriate. Beers guidance reserves them for cases where non-drug approaches have failed and there is a threat of substantial harm to the person or others.
How to prepare for a pharmacist medication review
A structured review, sometimes called deprescribing, works best when the pharmacist can see the whole picture. Bring everything, including products you may not think of as "real" medicine.
Do not stop or change doses on your own; abrupt withdrawal of benzodiazepines or antipsychotics can be dangerous. The pharmacist coordinates with the prescribing physician to make changes safely.
- Gather all prescriptions, OTC drugs, vitamins, and herbal supplements — bring the actual bottles or a photo of each label.
- Note why and how long each has been taken, plus any recent changes in confusion, sleep, mood, or falls.
- Ask directly: "Does this product have anticholinergic effects?" and "Is there a safer alternative for someone with dementia?"
- Ask about a slow, monitored taper rather than stopping sedatives or antipsychotics abruptly.
- Confirm who will follow up and when to judge whether a change helped.
Why these reviews matter so often
Potentially inappropriate medication use is common in people with dementia, which is why guidelines now push for regular, pharmacist-led reviews. A deprescribing analysis summarized on PubMed Central supports this routine approach alongside the 2023 Beers Criteria.
You do not need to memorize every drug name. The full AGS 2023 Beers Criteria drug list is a reference your pharmacist can walk through with you, matching each medication on your list against known risks.
Frequently Asked Questions
Are over-the-counter drugs really a concern?
Yes. Many strong anticholinergics, including diphenhydramine-based sleep and "PM" pain products, are sold without a prescription and are easy to overlook.
Can I just stop a risky medication myself?
No. Stopping benzodiazepines or antipsychotics suddenly can be dangerous. Ask a pharmacist or physician to plan a slow, monitored taper.
Are antipsychotics ever justified in dementia?
Only when non-drug approaches fail and there is risk of substantial harm, given the FDA boxed warning about increased death.
