Gabapentin Associated with Cognitive Decline & Dementia
New research suggests an association between the use of gabapentin and incidence of both cognitive impairment and dementia. In a retrospective cohort study, Eghrari and colleagues looked specifically at gabapentin prescriptions for low back pain. Patients who received six or more gabapentin prescriptions had an 85% higher risk of developing mild cognitive impairment and a 29% higher risk of developing dementia. The researchers found the risks were most pronounced for non-elderly patients, and risks increased with the number of prescriptions. The lead author told Medical News Today, “The significance of this finding is an association between gabapentin prescription and dementia on a nationwide level.”
For some time, geriatricians have been raising red flags about the cognitive effects of gabapentin. In a retrospective cohort study, Oh et al. measured changes in cognitive function and motor function among older adults prescribed gabapentin. Subjects had normal cognition at the outset and were compared over time with individuals who were not taking gabapentin. The researchers found that gabapentin was significantly associated with declines in both cognitive and functional status. The drug regimen was also associated with falls.
Gabapentin in nursing homes
Use of gabapentinoids among nursing home residents is “rapidly increasing,” according to a Clinician Perspectives piece published by Winter et al. in the Journal of the American Geriatrics Society in 2025. This may trace back to beliefs about gabapentin and gabapentinoid drugs.
Dr. Samir Tulebaev commented for Medscape, “Many clinicians still view gabapentin as benign” and “underestimate fall and delirium risk” associated with the drug. Geriatrician Awais Alam told Medscape, “Gabapentin should not be routinely prescribed to older adults due to a constellation of age-related risks and adverse effects.”
Gabapentin and BPSDs
Gabapentin is FDA-approved for the treatment of partial seizures, postherpetic neuralgia, and restless legs syndrome. However, some clinicians prescribe it off-label for other conditions, including behavioral and psychological symptoms of dementia (BPSDs).
There is no solid evidence base for using gabapentin to treat BPSDs, explains a GuideStar blog about anticonvulsants and BPSDs. A 2022 report from the Inspector General noted that as antipsychotic drug use declined in nursing homes in response to CMS policies, use of anticonvulsant drugs increased. Valproic acid and gabapentin are common examples of drugs in this category.
Gabapentin and older adults
The BEERS Criteria® call out the risk of pairing gabapentin with opioids, which could lead to severe sedation, respiratory depression, and heightened fall risk with gabapentinoids among older adults. Alam recommends that gabapentin “should be prescribed to older adults only after thorough evaluation of individual risk factors, with preference for the lowest effective dose and vigilant monitoring for neurocognitive and functional decline.”
More nursing home perspectives
For their Clinician Perspectives piece, Winter et al. surveyed nursing home clinicians to explore their attitudes and prescribing practices surrounding gabapentinoids. They found that:
- In contrast to perspectives cited above, many clinicians “perceive gabapentinoids as helpful” in moderating BPSDs.
- Many have selected gabapentinoids as a “less scrutinized” alternative to antipsychotics. (Winter et al.’s research preceded revised CMS guidance released in 2025.)
- There are “polarized beliefs” about safety and efficacy, with some clinicians expressing serious reservations about gabapentinoid use and others believing the drugs are effective and safe.
- Many residents who enter nursing homes are already on gabapentinoid regimens, so there is a downstream prescribing effect at play.
- Many clinicians find that gabapentinoids are easy to start and hard to stop.
- Gabapentinoids are “often initiated without clearly defined therapeutic goals or discontinuation criteria.”
CMS guidance
In its guidance for surveyors under F-605, CMS defines a psychotropic medication as “any drug that affects brain activities associated with mental processes and behavior”. Prescription of psychotropic drugs must meet the standard for “adequate indication for use” and must be subject to a gradual dose reduction protocol.
As underscored by the perspectives of nursing home clinicians, the care of residents living with dementia poses complex challenges. Research suggests that gabapentin is not a ready answer for behavioral and psychological concerns. Furthermore, residents who are taking gabapentin for pain or any other reason may face heightened risk of cognitive decline and/or falls.
Pharma review essential
GuideStar Eldercare’s evidence-based, neurology-forward approach to antipsychotic stewardship includes protocols for polypharmacy review, as many common nursing home medications can affect cognitive and psychological status. GuideStar’s clinical practices are designed to enhance the quality of life for nursing home residents, actively promoting safety, functionality, and dignity.
For help with pharmacological review, management of dementia symptoms, GDR, and CMS compliance, reach out to the GuideStar team. We’re here to help.