For decades, clinical guidelines have cautioned clinicians about prescribing certain central nervous system active medications to older adults. These drugs, while sometimes clinically necessary, are associated with increased risks of delirium, falls, fractures, hospitalizations, and mortality. The risks are especially pronounced among older adults with cognitive impairment or dementia. Despite this long standing guidance, potentially inappropriate CNS active medications continue to be prescribed at notable rates across the United States.
A newly published research letter in JAMA sheds important light on how prescribing patterns for these medications have changed over time. Using nationally representative data, the study examines trends from 2013 through 2021 and highlights persistent disparities among older adults with cognitive impairment no dementia and dementia. The findings provide both encouraging signals of progress and sobering evidence that significant opportunities for safer prescribing remain.
This article breaks down the study’s findings, explains why they matter, and explores what they mean for clinicians, caregivers, health systems, and policymakers focused on improving medication safety in aging populations.
Potentially inappropriate medications are drugs that pose higher risks than benefits for older adults, particularly when safer alternatives exist. The American Geriatrics Society Beers Criteria serves as the most widely used reference for identifying these medications.
In this study, CNS active medications were defined based on the 2012 and 2019 Beers Criteria and included five drug classes:
These medications can impair cognition, slow reaction time, and increase sedation. In older adults, especially those with cognitive impairment, these effects can lead to serious adverse outcomes.
Older adults are not a uniform group. Cognitive health plays a critical role in determining how individuals respond to medications. Those with cognitive impairment no dementia or diagnosed dementia are more vulnerable to adverse drug effects due to altered brain chemistry, reduced physiologic reserve, and higher rates of comorbidity.
Clinical guidelines consistently advise extra caution or outright avoidance of high risk CNS active medications in patients with cognitive impairment. Yet real world prescribing often deviates from these recommendations, influenced by fragmented care, limited access to nonpharmacologic treatments, and the challenges of managing behavioral symptoms.
Understanding how prescribing patterns differ by cognitive status is essential for targeting deprescribing interventions and improving patient safety.
The JAMA research letter analyzed data from the Health and Retirement Study linked with Medicare fee for service claims between 2013 and 2021. Participants included adults aged 65 years and older with at least two years of continuous Medicare Parts A, B, and D coverage.
Cognitive status was categorized using the Langa Weir classification into three groups:
Researchers examined whether beneficiaries received one or more potentially inappropriate CNS active prescriptions with a supply of 28 days or longer during each study year.
Secondary analyses assessed whether prescriptions were associated with documented clinical indications, such as schizophrenia for antipsychotic use, based on ICD 9 and ICD 10 diagnosis codes.
From 2013 to 2021, the proportion of older adults receiving at least one potentially inappropriate CNS active medication declined from 19.9 percent to 16.2 percent. This represents a statistically significant decrease and suggests growing awareness of medication risks in older populations.
However, the overall prevalence remains substantial. Roughly one in six Medicare beneficiaries aged 65 and older received a potentially inappropriate CNS active medication in 2021.
The study found clear disparities based on cognitive status:
These differences were statistically significant and persisted after adjusting for age, sex, race and ethnicity, comorbidities, and socioeconomic status.
The findings underscore that patients most vulnerable to harm are also the most likely to receive high risk medications.
Encouragingly, reductions in prescribing were not uniform across all drug classes. The most meaningful declines occurred in:
These declines likely reflect increased attention to fall risk, sleep hygiene education, and regulatory scrutiny around sedative hypnotics.
In contrast, prescribing rates for antipsychotics, antidepressants with anticholinergic properties, and barbiturates did not significantly change over the study period.
One of the most striking findings involved the presence or absence of documented clinical indications.
Between 2013 and 2021, there was no significant change in the proportion of prescriptions with a documented indication. However, prescriptions without a clear clinical indication declined meaningfully from 15.7 percent to 11.4 percent.
Despite this improvement, the majority of potentially inappropriate prescriptions remained unsupported by documented indications. In 2021, among beneficiaries receiving these medications, 70.4 percent lacked a qualifying diagnosis.
This highlights a major quality of care gap and suggests that many older adults are exposed to medication risks without clear evidence of benefit.
Several factors contribute to ongoing use of potentially inappropriate CNS active medications:
For patients with dementia, behavioral and psychological symptoms are especially challenging to manage, leading to reliance on medications despite known risks.
The findings point to several actionable opportunities:
At the policy level, these findings support continued investment in value based care models, medication therapy management programs, and quality measures that prioritize medication safety in older adults.
As the population ages and dementia prevalence rises, the stakes for safer prescribing will only increase.
The decline in potentially inappropriate CNS active medication prescribing over the past decade is a meaningful achievement. However, the persistence of high use among older adults with cognitive impairment and the prevalence of prescriptions without clinical indications reveal ongoing risks.
This study reinforces the need for sustained efforts in deprescribing, education, and system level interventions. Improving medication safety for older adults is not only a clinical priority but also a moral imperative as we strive to deliver care that maximizes benefit while minimizing harm.
Yang AW, Leng M, Ly DP, et al. Prescribing Patterns of Potentially Inappropriate CNS-Active Medications in Older Adults. JAMA. Published online January 12, 2026. doi:10.1001/jama.2025.23697
This blog is for informational and educational purposes only and is not intended as medical advice. Clinical decisions should be made based on individual patient circumstances and in consultation with qualified healthcare professionals. The views summarized here are based on the cited research and do not necessarily reflect the views of any government agency or healthcare institution.
