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Polypharmacy and Medication Review in Advanced Dementia

In advanced dementia, taking five or more medications (polypharmacy) is very common, affecting about half of all individuals. This often includes drugs that may no longer be helpful or could even be harmful. The good news is that there are concrete, step-by-step ways to review and simplify medications, improving comfort and quality of life. You are not alone in navigating this, and small changes can make a big difference.

Key points

  • Polypharmacy (5+ medications) affects about half of people with advanced dementia and increases risks of confusion, falls, and side effects.
  • There is no standard review process, so caregivers must proactively request a dedicated medication review appointment.
  • Use the Beers Criteria to identify potentially inappropriate medications, especially anticholinergics and benzodiazepines.
  • Bring all medications (including OTC and supplements) to every appointment in a bag for a complete review.
  • Deprescribing should be done one drug at a time, under medical supervision, with careful monitoring for changes.
  • In late-stage dementia, focus on comfort and quality of life; many preventive drugs can be safely stopped.

Why Polypharmacy Happens in Advanced Dementia

People with advanced dementia often have multiple chronic conditions, like high blood pressure, diabetes, or heart disease, which require medications. As dementia progresses, the person may also develop behavioral symptoms like agitation, anxiety, or sleep problems, leading doctors to prescribe psychotropic drugs such as sedatives, antidepressants, or antipsychotics. Over time, the medication list can grow without regular review, and drugs that were once helpful may become unnecessary or even harmful.

The Risks of Polypharmacy in Late-Stage Dementia

Taking many medications increases the risk of drug-drug interactions, side effects, and adverse events. In advanced dementia, the brain is especially vulnerable to drugs that affect cognition, such as anticholinergics (found in some allergy, sleep, and bladder medications) and benzodiazepines. These can worsen confusion, increase fall risk, and reduce quality of life. Studies suggest that more than one in four older adults with dementia use potentially inappropriate anticholinergic medications, which may accelerate cognitive decline.

Why a Standardized Review Process is Lacking

Despite the high risk, there is no universally accepted standard for reviewing medications in this population. Many primary care providers are not trained in geriatric pharmacology, and busy clinics may not have time for a thorough review. This means caregivers must be proactive in asking for a medication review, ideally with a geriatrician, neurologist, or pharmacist who specializes in dementia care.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Gather all medications, including prescriptions, over-the-counter drugs, vitamins, supplements, and any herbal remedies. Place them in a bag and bring them to every doctor appointment. This ensures nothing is missed.

  2. Create a complete, up-to-date written list with the name, dose, frequency, and purpose of each medication. Include the date of the last update. Share this with every healthcare provider.

  3. Ask the doctor or pharmacist to review the list using a tool like the American Geriatric Society's Beers Criteria, which identifies potentially inappropriate medications for older adults. Specifically ask: 'Are any of these medications on the Beers list? Can we stop or switch them?'

  4. For each medication, ask: 'Is this still necessary given the stage of dementia? Could it be causing side effects like confusion, falls, or drowsiness? Is there a safer alternative?'

  5. If the person has been on a dementia medication (like donepezil, rivastigmine, or memantine) for more than six months, ask the doctor to reassess whether it is still providing benefit. In advanced stages, these drugs may no longer be helpful and can be discontinued.

  6. Review all psychotropic medications (antidepressants, antipsychotics, sedatives) at least every three months. Ask: 'Is this still needed? Can the dose be lowered? Are there non-drug approaches we can try first?'

  7. Check for anticholinergic drugs, which are often hidden in over-the-counter products like sleep aids (e.g., diphenhydramine in Tylenol PM, Advil PM, ZzzQuil) and bladder medications. Ask the pharmacist to flag any with strong anticholinergic effects.

  8. Work with the care team to taper off any unnecessary medications slowly, one at a time, to avoid withdrawal or rebound symptoms. Never attempt to taper any medication on your own; always follow a clinician's precise instructions.

  9. Document any changes in behavior, sleep, appetite, or mobility after a medication is reduced or stopped. Share these observations with the doctor to guide further adjustments.

What not to do

  • Do not assume that all medications prescribed months or years ago are still needed. Many drugs for chronic conditions (like cholesterol or blood pressure) may no longer be appropriate in advanced dementia. Instead, ask for a 'deprescribing' review focused on quality of life.

  • Do not stop medications suddenly without medical supervision. Some drugs, like antidepressants or antipsychotics, can cause withdrawal symptoms or a return of severe behavioral issues if stopped abruptly. Always taper under a doctor's guidance.

  • Do not ignore over-the-counter medications and supplements. Products like diphenhydramine (found in many 'PM' sleep aids) can worsen confusion and fall risk. Bring all non-prescription items to the review.

  • Do not assume that a medication is safe just because it is 'natural' or 'herbal.' Some supplements (e.g., St. John's Wort, ginkgo biloba) can interact with prescription drugs. Always disclose everything to the healthcare team.

  • Do not wait for the doctor to suggest a medication review. In busy practices, it may not happen unless you ask. Be persistent and schedule a dedicated appointment focused solely on medications.

Practical tools

  • The Medication Bag Method

    Place ALL medications (prescription, OTC, supplements) into a single bag. Bring this bag to every medical appointment. This ensures the doctor sees exactly what is being taken, including any recent changes or new items.

  • The 'Is This Still Needed?' Checklist

    For each medication, ask these three questions: (1) Is this drug still necessary for this person at this stage of dementia? (2) Could it be causing side effects like confusion, falls, or drowsiness? (3) Is there a safer alternative? Write down the answers and discuss with the prescriber.

  • The Beers Criteria Quick Reference

    Ask your pharmacist or doctor to check the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. This list includes drugs to avoid or use with caution in dementia, such as anticholinergics, benzodiazepines, and certain pain medications. You can find a free version online at geriatricscareonline.org.

  • The 'One-at-a-Time' Tapering Plan

    When stopping a medication, work with the doctor to taper one drug at a time. Never attempt to taper any medication on your own; always follow a clinician's precise instructions. Schedules vary widely based on the drug, dose, and individual health. Keep a daily log of any changes in behavior, sleep, or mobility to share with the care team.

  • The Medication Review Appointment Script

    When scheduling an appointment, say: 'I would like a dedicated medication review for my loved one with advanced dementia. We need to discuss which drugs are still necessary and which can be stopped or reduced. Please allow extra time for this.' This sets the expectation for a thorough review.

  • The 'Anticholinergic Burden' Calculator

    Use an online anticholinergic burden calculator (e.g., from the Aging Brain Care Institute) to score each medication. Drugs with a score of 2 or 3 (like amitriptyline, oxybutynin, diphenhydramine) should be prioritized for deprescribing. Share the results with the doctor.

Discuss with your clinician

Ask your doctor: 'Is it safe to stop any of my loved one's preventive medications (like statins or blood pressure drugs) given their advanced dementia?'

Ask the pharmacist: 'Which of these medications have anticholinergic properties? Can we switch to a safer alternative?'

Ask the neurologist: 'Should we discontinue the dementia medication (donepezil, rivastigmine, memantine) since my loved one is in the late stage?'

Ask the geriatrician: 'Can you help us create a deprescribing plan that tapers off one medication at a time? What specific dose reductions and time frames are right for my loved one?'

Ask the hospice team (if applicable): 'How do we prioritize comfort over disease prevention in medication management?'

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