Neurologists and geriatric specialists recommend that dementia patients avoid several classes of medications, including anticholinergics, benzodiazepines, antipsychotics, opioids, and certain medications for overactive bladder, pain, and heartburn. These drugs can worsen cognitive decline, increase fall risk, cause confusion, and in some cases, raise the risk of death in people already living with dementia. For example, a patient taking an over-the-counter cold medication with anticholinergic properties might experience accelerated memory loss over months without realizing the medication itself is contributing to their decline.
This article explores why these medications pose particular risks for dementia patients, what the latest medical guidelines say, and how caregivers and patients can work with doctors to find safer alternatives. The evidence against these medications has become increasingly clear over the past decade. Research published in major medical journals, combined with updated guidance from the American Geriatrics Society, now provides healthcare providers with concrete recommendations about which drugs to avoid and what to use instead. Understanding this list matters because the problem is widespread: approximately 25% of dementia patients are prescribed at least one of these risky medications, and in more than two-thirds of cases, doctors have no documented clinical justification for the prescription.
Table of Contents
- Why Anticholinergic Medications Are Particularly Concerning for Dementia Patients
- Benzodiazepines and the Risk of Sedation and Cognitive Impairment
- Antipsychotics and Behavioral Medication Dangers
- Opioids, Overactive Bladder Medications, and Other Drug Classes to Reconsider
- The Current Prescribing Crisis and Why Risky Medications Persist
- Understanding the 2023 Beers Criteria and Latest Medical Guidance
- Taking Action—Medication Reviews and Conversations with Providers
- Conclusion
Why Anticholinergic Medications Are Particularly Concerning for Dementia Patients
Anticholinergic medications block a neurotransmitter called acetylcholine, which plays a crucial role in memory and cognition. people taking anticholinergic drugs daily for three or more years face a 50% increased chance of developing dementia. Research published in JAMA Internal Medicine and other peer-reviewed sources has established a dose-dependent relationship—meaning the longer someone takes these medications and the higher the dose, the greater the risk. This isn’t a marginal effect; a systematic meta-analysis found that anticholinergic use is associated with a 1.20-fold increased risk of all-cause dementia, a significant elevation for a preventable exposure. These medications hide in plain sight. Patients might be taking them for urinary incontinence, allergies, cold symptoms, muscle spasms, or Parkinson’s disease—often without realizing they’re anticholinergic.
Dr. Glen R. Finney, director of the Geisinger Memory and Cognition Program, explains the concern plainly: “Growing evidence suggests long-term use of anticholinergic medications can be harmful to your brain health and may even raise your risk of dementia.” For someone already diagnosed with dementia, continued use accelerates cognitive decline and increases the risk of behavioral problems, hallucinations, and delirium. The challenge is that many people have been on these medications for years, sometimes decades, for legitimate conditions. Simply stopping them abruptly can be dangerous—some anticholinergic medications require gradual tapering. This is why working with a healthcare provider to identify which anticholinergics might be discontinued or replaced with safer alternatives is essential, rather than stopping medications on your own.
Benzodiazepines and the Risk of Sedation and Cognitive Impairment
Benzodiazepines—drugs like diazepam, lorazepam, and alprazolam—slow central nervous system function, which can cause sedation, memory loss, vivid or disturbing dreams, and irritability. For a person with dementia, these side effects are particularly dangerous. While these medications might be prescribed for anxiety or insomnia (both common in dementia), they often make the underlying condition worse by increasing confusion, raising fall risk, and creating a cycle of dependency. The problem is compounded because dementia patients metabolize medications differently than younger adults. Their bodies clear benzodiazepines more slowly, meaning a standard dose can accumulate in their system and cause prolonged cognitive effects.
A person with dementia taking even a modest dose of lorazepam for anxiety might spend days in a fog, unable to recognize family members or participate in daily activities. Over time, benzodiazepine dependence becomes its own problem, separate from the original condition the medication was meant to treat. However, if a patient has been on benzodiazepines for many years, abrupt discontinuation can trigger dangerous withdrawal symptoms. Switching to non-medication approaches—such as structured routines, music therapy, or environmental modifications—often works better for dementia-related anxiety and sleep problems. The goal should be gradual tapering under medical supervision, not sudden cessation.
Antipsychotics and Behavioral Medication Dangers
Antipsychotic medications are sometimes prescribed to manage behavioral problems in dementia, such as agitation or aggression. However, the evidence against this practice is stark. Antipsychotics increase the risk of death in people with dementia—a sobering reality that has led to black box warnings and strong clinical guidance against their use. The 2023 Beers Criteria, the most current and authoritative guidelines for medication safety in older adults released by the American Geriatrics Society, specifically recommends avoiding antipsychotics for behavioral issues in dementia patients and emphasizes non-pharmacological approaches instead. Non-medication strategies—such as identifying triggers for behavior changes, maintaining consistent routines, ensuring adequate sleep and nutrition, and providing meaningful activities—are often more effective than drugs and carry no risk of serious harm.
When behavioral issues do require intervention, alternatives to antipsychotics exist, and healthcare providers are increasingly trained to try these first. For example, a patient becoming aggressive due to pain from an untreated urinary tract infection will improve when the infection is treated, not when given an antipsychotic. The reason antipsychotics are sometimes still prescribed despite these risks is partly inertia—they’ve been used in dementia care for decades—and partly the difficulty of managing severe behavioral problems without medication. However, as research accumulates and guidelines become clearer, this practice is shifting. Caregivers and family members should feel empowered to question antipsychotic prescriptions and ask about alternatives.
Opioids, Overactive Bladder Medications, and Other Drug Classes to Reconsider
Opioid pain medications have now been added to the 2023 Beers Criteria as drugs that can exacerbate delirium in dementia patients. Beyond causing confusion, opioids increase constipation (a major problem in dementia care), contribute to falls, and carry a risk of addiction. For chronic pain in dementia patients, non-opioid alternatives—such as physical therapy, topical pain relievers, and non-opioid oral medications—should be tried first. Overactive bladder medications, certain pain medications, and heartburn medications like anticholinergic antacids have all been associated with increased dementia risk. These medications are particularly insidious because they’re often available over-the-counter or prescribed without specific discussion about dementia risk.
A patient or caregiver might not realize that the medication for nighttime urination or indigestion is contributing to cognitive decline. Heartburn is common in older adults and in people with dementia, often because swallowing becomes impaired. However, long-term use of certain antacid classes carries dementia risk. Proton pump inhibitors (PPIs) are generally considered safer alternatives for chronic heartburn, though even these should be used at the lowest effective dose for the shortest duration necessary. Similarly, overactive bladder medications have safer alternatives, including behavioral interventions like scheduled toileting and fluid management.
The Current Prescribing Crisis and Why Risky Medications Persist
A major 2026 study found that 25% of dementia patients are prescribed at least one medication that neurologists consider risky. More troubling, in more than 66% of these cases, the patient’s medical records contained no documented clinical justification for the prescription. This suggests that many of these medications are being prescribed out of habit, without careful consideration of whether the benefit for dementia patients outweighs the harm. Several factors contribute to this gap between guidelines and practice. First, many doctors trained decades ago, when these medications were standard dementia treatment.
Updating prescribing practices takes time. Second, deprescribing—removing unnecessary or harmful medications—is harder than prescribing them. Patients and families may be reluctant to stop a medication they’ve been taking for years, even when a doctor recommends it. Third, managing dementia-related symptoms like insomnia, anxiety, and agitation without medication requires time, expertise, and coordinated care that isn’t always available. Breaking this cycle requires proactive conversations. Caregivers should ask their healthcare provider: “Is this medication on the list of drugs to avoid in dementia?” and “What would happen if we tried discontinuing or reducing this medication?” Many medication reviews reveal opportunities to safely reduce or eliminate risky drugs, improving cognitive function and overall quality of life.
Understanding the 2023 Beers Criteria and Latest Medical Guidance
The American Geriatrics Society’s Beers Criteria is the gold standard for identifying potentially inappropriate medications in older adults. The most recent update, released in 2023, with a July 2025 companion resource, provides detailed guidance on which drugs to avoid in dementia and what alternatives to use instead. These criteria are evidence-based, updated regularly, and specifically designed to reduce harm in vulnerable populations. The 2023 Beers Criteria goes beyond just listing drugs to avoid; it provides alternative treatment recommendations. For anxiety, instead of benzodiazepines, it recommends cognitive-behavioral therapy, mindfulness practices, or selective serotonin reuptake inhibitors (SSRIs) at lower doses.
For insomnia, instead of sedating medications, it recommends sleep hygiene, light therapy, and other behavioral approaches. For pain, it recommends physical therapy, topical agents, and non-opioid oral medications. These alternatives often work better for dementia patients while carrying far less risk. Healthcare providers can access these guidelines through the American Geriatrics Society website and through their professional associations. Patients and caregivers can also review the guidelines independently to understand what medications raise concern and what alternatives exist. Using these criteria in conversations with doctors helps ensure that medication choices are truly evidence-based.
Taking Action—Medication Reviews and Conversations with Providers
The first step is a comprehensive medication review, ideally conducted by a pharmacist familiar with dementia care or a geriatrician. This review should examine every medication the person is taking, asking: Is this medication necessary? Is there a safer alternative? Can the dose be reduced? This process, called deprescribing, has been shown to improve cognition, reduce falls, and enhance overall quality of life in dementia patients. When requesting a medication review, bring a complete list of all medications, supplements, and over-the-counter drugs. Include prescription bottles if possible, as this prevents errors. Ask specifically about anticholinergics, benzodiazepines, antipsychotics, and opioids.
If any of these are on the list, ask the doctor to explain the clinical justification and what would happen if the medication were gradually discontinued. Many medications can be safely tapered or replaced with better alternatives, but this requires planning and monitoring. The conversation should also address the person’s goals. Does the patient prioritize living longer, maintaining cognitive function, managing specific symptoms, or something else? Medications that might be justified for a 40-year-old with a single condition may not align with the values and priorities of a person living with dementia. Open, collaborative conversations between patients, families, and healthcare providers lead to medication lists that actually support quality of life.
Conclusion
Neurologists and geriatric specialists have identified a clear list of medications that dementia patients should avoid: anticholinergics, benzodiazepines, antipsychotics, opioids, and several other drug classes. The evidence is robust, the harms are significant, and safer alternatives exist for most conditions these medications treat. Yet despite clear guidelines, these medications remain widely prescribed in dementia care, often without documented justification, causing unnecessary cognitive decline and other harm.
The path forward requires action at multiple levels. Patients and caregivers should ask their healthcare providers about medication reviews and specifically about whether any medications on the avoid list are being taken. Healthcare providers should prioritize deprescribing, using the 2023 Beers Criteria as a guide, and exploring non-medication approaches to managing common dementia symptoms. Together, these efforts can reduce unnecessary medication exposure, improve cognition, and help people with dementia maintain the best possible quality of life.
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For more, see Alzheimer’s Association — medical tests.
