In Brief
After cognitive impairment is identified, the medication list becomes a treatment target in its own right. Anticholinergic and sedating medications can contribute to confusion, impaired attention, daytime sedation, falls, and reduced daily function. The burden may come from one high-risk drug and often grows when several are combined. Primary care is well positioned to do this work because the primary care physician typically knows why each medication was started and what tradeoffs the patient and care partner will accept. A structured review builds a complete list, identifies high-risk targets, ties each change to a goal, tapers when needed, and reassesses function. Deprescribing acts on the regimen rather than on the underlying disease, and it can still change what a family is able to manage.
Why deprescribing belongs in dementia care
After a dementia diagnosis, most of the conversation between clinicians and families turns to what can be added: a new medication, a specialist consultation, a community resource, a safety device, a therapy referral. Many of those additions are appropriate. But one of the most useful questions in early dementia management runs in the other direction: What can the patient safely stop taking?
For many older adults, the medication list is a modifiable contributor to cognitive and functional risk. Long-term exposure to some strong anticholinergic drug classes has been associated with a higher risk of dementia in observational studies. A patient may be taking an antimuscarinic bladder medication, an over-the-counter sleep aid, a first-generation antihistamine, a tricyclic antidepressant, a muscle relaxant, a benzodiazepine, or a combination of central nervous system (CNS)–active medications, each of which may have made sense when prescribed. Over time, the cumulative effect may be confusion, fatigue, falls, constipation, urinary retention, impaired attention, or a declining ability to manage daily life.
Deprescribing is often described as doing less for the patient. In dementia care it functions as active treatment, with a defined target, a monitoring plan, and a result the family can observe.
The anticholinergic problem
Anticholinergic medications block acetylcholine signaling, and cholinergic pathways carry much of the work of attention, learning, and memory. That produces a clinical tension: many of the symptomatic medications used in Alzheimer's disease are prescribed to increase cholinergic signaling, while anticholinergic drugs push in the opposite direction.
The issue may involve one strongly anticholinergic medication or cumulative medication burden. Several drugs with weaker anticholinergic effects can add together. A patient may also be taking sedating medications that work through other mechanisms and still worsen cognition, balance, and function. The regimen can become internally contradictory, with one drug prescribed to support cognition while another works quietly against it.
Medication review after cognitive impairment is identified must therefore reach well beyond the refill list. It should cover prescriptions, over-the-counter products, sleep aids, bladder medications, allergy medications, pain medications, psychiatric medications, supplements, and drugs prescribed by other clinicians.
Why this work belongs in primary care
Specialists are essential for many patients, but the longitudinal work of managing the entire medication ecosystem usually remains in primary care. A neurologist may recommend a cholinesterase inhibitor, evaluate for atypical disease, or assess eligibility for an Alzheimer's therapy. The primary care clinician is usually the person who understands why the patient is on each medication, which prescriber started it, which symptom it was meant to treat, and what tradeoffs the patient and care partner are willing to accept.
Primary care also sees the consequences: a daughter reports that her father is more confused at night, a spouse says the patient sleeps through most of the day, or a fall follows a medication change by a week. Constipation, dizziness, dry mouth, urinary retention, or delirium may never be recognized as medication-related, but each can substantially affect the patient's quality of life.
Deprescribing requires longitudinal trust. It often requires saying, "This medication may have helped at one point, but the risk-benefit balance may have changed." That conversation fits naturally in primary care.
A practical deprescribing process
A safe medication review is structured, conservative, and shared with the patient and care partner. A useful approach is:
- Start with a complete list. Ask the patient or caregiver to bring every bottle, including over-the-counter sleep aids, allergy medications, bladder medications, pain medications, and supplements. Reconcile that list against the electronic health record and pharmacy fill history when available.
- Identify the highest-risk targets. Prioritize strongly anticholinergic medications, sedative-hypnotics, benzodiazepines, high-risk CNS combinations, medications that have outlived their indication, and drugs causing orthostasis, sedation, constipation, urinary retention, or delirium.
- Connect each target to a goal. Tie every change to an outcome the patient or family will recognize: more alert mornings, fewer falls, less confusion, improved appetite, easier bowel movements, better participation in daily activities, or fewer medication errors.
- When clinically safe, change one or two things at a time. Families need to know what is being changed and why. Too many changes at once can create rebound symptoms, obscure cause and effect, and reduce trust.
- Taper when needed. Do not assume every target can be stopped abruptly. Benzodiazepines should not be discontinued abruptly when physical dependence is likely; antidepressants, antipsychotics, nonbenzodiazepine hypnotics, opioids, gabapentinoids, and other medications may also require individualized, drug-specific dose reduction to limit withdrawal, rebound symptoms, or recurrence of the treated condition.
- Substitute thoughtfully. Deprescribing is not abandonment. It may mean bladder training, sleep hygiene, a referral for cognitive behavioral therapy for insomnia, a less anticholinergic, less sedating antihistamine when the indication remains valid, nonpharmacologic pain strategies, physical therapy, or safer pharmacologic alternatives.
- Reassess cognition and function. Success is measured in the patient's condition rather than in the length of the list. Recheck alertness, falls, sleep, mood, bowel and bladder symptoms, caregiver burden, and ability to perform daily activities.
The caregiver is part of the intervention
When a care partner helps manage medications, that person is an important part of safe deprescribing and should be involved with the patient's agreement or applicable surrogate authority. The care partner often knows which pill causes daytime sleepiness, which medication the patient takes twice by mistake, and which symptom the family fears will return if a drug is stopped.
Care partners should be explicitly invited to report what they see. A simple follow-up instruction, such as "Call us if sleep worsens, agitation increases, falls occur, or the original symptom returns," turns deprescribing into monitored care rather than a one-time change to the list.
Billing and workflow: making invisible work visible
Medication optimization takes time. It involves history, reconciliation, risk review, shared decision-making, taper plans, follow-up, and documentation. That work has often been invisible, and cognitive care planning frameworks increasingly recognize it as core dementia care.
For eligible Medicare patients, clinicians may use CPT 99483 to report a comprehensive cognitive assessment and care-planning visit when its requirements are met; medication reconciliation and review for high-risk medications are among those required elements. The code makes none of the clinical work simpler, and billing rules should always be verified locally. But it does signal a shift: thoughtful medication management belongs inside the care plan rather than alongside it as an optional courtesy after a dementia diagnosis.
A composite case
Consider an 82-year-old woman with mild dementia who comes in with her son. Her cognitive score has declined, and the son is most worried that she is foggy in the morning and has fallen twice. Her medication list includes diphenhydramine for sleep, oxybutynin for overactive bladder, a benzodiazepine she has taken for years, and a new cholinesterase inhibitor.
The plan targets harm added by the regimen rather than the underlying disease. Because the cholinesterase inhibitor is new and falls have occurred, the clinician also reviews the timing of symptoms, pulse and orthostatic vital signs, weight and appetite, and other heart-rate-lowering drugs. After confirming her understanding and preferences, the patient and her son agree to stop diphenhydramine first, shift from oxybutynin to a lower-risk bladder strategy, and begin a slow benzodiazepine taper once she is stable. Over the next several weeks, they report better morning alertness. She has had no further falls, and the clinician continues monitoring falls, function, and withdrawal symptoms.
That is dementia care as it usually looks in practice: undramatic, often handled largely within primary care, and measurable in ways that are meaningful to the family.
The medication list is a treatment target
Deprescribing acts on the medication regimen rather than on the underlying neurodegenerative disease, and families deserve to hear it described in those terms. Evidence that reducing anticholinergic burden improves cognition remains insufficient and of very low certainty. In an individual patient, however, a monitored trial of reducing medications that plausibly contribute to sedation, delirium, orthostasis, falls, constipation, urinary retention, or impaired function may still improve symptoms or daily function. The medication list is not housekeeping after a dementia diagnosis. It is part of the treatment.
Written by Dr. Anthony Zizza, Chief Medical Officer, Element Care
Dr. Zizza is a board-certified geriatrician and chief medical officer at Element Care, a PACE (Program of All-Inclusive Care for the Elderly) organization, where he integrates cognitive care within value-based frameworks. He earned his MD at the University of Massachusetts and completed a fellowship in Geriatric Medicine at Harvard. He serves as an advisory board member at Creyos.