JAMA Netw Open
Drugs risky for cognition linger after acute elder care
Clinical takeaway: Deprescribing efforts may have the greatest impact if they target emergency departments, hospitals, and skilled nursing facilities where many cognition-affecting medications are often started.
Medications such as benzodiazepines, hypnotics, antipsychotics, and anticholinergics can increase delirium, confusion, and fall risk in older adults, yet they remain commonly prescribed. This study examined where these medications are initiated and how often use continues long after the initial prescription.
New prescriptions were more likely to start in acute or post-acute settings than expected based on overall visit patterns. Among patients with dementia starting an antipsychotic, 43.3% had most recently been in an emergency department, hospital, or skilled nursing facility, even though only 22.0% of their overall visits were to those settings.
The pattern persisted. Across all four medication classes, 21.9% of patients with dementia started a cognition-affecting medication in an acute or postacute setting, and 51.2% were still taking a medication in the same class one year later. For antipsychotics specifically, 67.1% of patients with dementia who started treatment were still using an antipsychotic-class medication a year later.
Researchers analyzed Health and Retirement Study data linked to Medicare fee-for-service claims from 2008 to 2021. The study included adults age 66 years or older and identified 4,955 new medication starts, representing an estimated 23.4 million first prescriptions among Medicare beneficiaries. The analysis focused on benzodiazepines, nonbenzodiazepine hypnotics, antipsychotics, and anticholinergics, with patients grouped by cognitive status.
The findings suggest that short-term prescribing in high-acuity settings can become long-term exposure, even in patients most vulnerable to cognitive and safety harms. The study inferred the prescribing setting from the last clinical setting before the first fill, so it could not prove precisely where each prescription originated.
“Medications such as antipsychotics and benzodiazepines are known to affect cognition, increase delirium, and increase fall risk for older adults,” said lead author Dan Ly, MD, PhD, MPP, assistant professor of medicine at the David Geffen School of Medicine at UCLA and VA Greater Los Angeles. “In addition, prescriptions for these medications are ‘sticky’ and persistent”
Source: Ly DP. JAMA Netw Open. 2026 Apr 28. Initiation Setting and Persistence of Medications Affecting Cognition in Older Adults