Well-being and cognitive enhancement

W — the second step

Reducing a medication list without putting anything in its place is not deprescribing; it is withdrawal. The second letter of DWARAA is the substitution — what the person gets instead — and it is planned before the reduction, not after it.

The substitution is the whole point

A resident on a nightly sedative is being given something for a problem. It may be the wrong something, and the problem may not be the one on the chart, but the problem is real. Removing the drug and supplying nothing leaves the person with the original problem plus a withdrawal syndrome, and the predictable result is that the drug goes back on within a month and everyone concludes deprescribing does not work.

For insomnia, the substitution has better evidence than the drug it replaces. The American College of Physicians gives cognitive behavioral therapy for insomnia a strong recommendation as the initial treatment for all adults with chronic insomnia, and gives drug therapy only a weak, second-line, short-term recommendation contingent on shared decision-making. The American Academy of Sleep Medicine reaches the same asymmetry using the same method: its behavioral recommendation is strong, and every one of its pharmacologic recommendations is weak.

And it works at this age. A meta-analysis of 23 randomized trials found that adults over 55 showed improvements in sleep quality, sleep latency and wake-after-sleep-onset similar in magnitude to those in middle-aged adults. A randomized, double-blind, placebo-controlled trial of 46 older adults with chronic primary insomnia, using clinical polysomnography, found cognitive behavioral therapy outperformed zopiclone on three of four outcomes at six months, while zopiclone did not differ from placebo on most.

The environment is an intervention

Bright natural light, large legible signage, visible clocks and calendars, calm decor without disorienting patterns, controlled temperature and controlled noise are not decor decisions. A resident who cannot tell what time it is, in a corridor that looks like every other corridor, under fluorescent light with a television going, has been given six reasons to be agitated before anyone has spoken to them.

None of that is a treatment for dementia. All of it changes what the next twenty minutes look like, and twenty minutes is frequently what is actually needed. The non-pharmacological step covers the full set.

The four levers

1. Cognitive stimulation. Structured activity matched to what the person can still do. Pitched too high it produces failure and agitation; pitched too low it produces disengagement. The match is the intervention, not the activity.
2. Physical activity. Safe enclosed outdoor space and daily movement. Movement is also the most reliable lever on the sleep disruption that drives late-day agitation.
3. Social engagement. Which requires enough staff for individualized attention to be possible at all. In a memory-care unit, staffing ratio is a clinical variable, not a labor-cost line.
4. Environmental modification. Light, signage, clocks, calm decor, temperature, noise. Six items, all inexpensive, all routinely skipped.

Cognition and comfort are not separable

A person in pain who cannot report pain will present as agitated, and agitation gets treated — usually with something sedating, which makes the pain harder to detect and the person harder to assess. That is the loop this step exists to interrupt. Regular pain assessment designed for residents who cannot tell you, and non-drug relief tried first — positioning, warmth, comfort items — is the correction. Pain in residents who cannot tell you.

Metabolic health is cognitive health

Glycemic control, blood pressure and vascular health are not a separate subject from cognition in an older adult. That is one reason the medication review and the cognitive picture belong in the same conversation rather than in two different meetings.

Common questions

If we stop a sleeping tablet, what happens to sleep?

That depends entirely on what replaces it and how the reduction is done. Sedative-hypnotics in adults over 60 buy about 25 extra minutes of total sleep, while adverse cognitive events are nearly five times as common as on placebo. Cognitive behavioral therapy for insomnia is the guideline-recommended first-line treatment and holds up in older adults. The reduction still has to be tapered and supervised. Z-drugs and sleep in older adults.

Is music therapy a treatment for dementia?

It is honestly listed as a meaningful activity rather than as a therapy for the disease, and that framing is the accurate one. Music tied to a person’s own history does not change the trajectory of dementia, and it reliably changes the next twenty minutes for a great many people. The eight non-pharmacological items.

DWARAA is six steps. Back to the framework overview.

Several of these drugs impair cognition by design — through different mechanisms

This is worth stating in one place, because on any individual medication list it is invisible. For several of the classes most commonly prescribed in this population, cognitive impairment during use is a direct pharmacological consequence of how the drug works. It is not an idiosyncratic side effect and it is not in dispute.

Class	Mechanism	What it produces	Certainty
Benzodiazepines, including the hypnotics — temazepam, triazolam, flurazepam, estazolam, quazepam	GABA-A positive allosteric modulation, α1 and α5 subtypes	Anterograde amnesia — impaired formation of new memory, with memory formed before the dose intact	Certain. Mechanistic. Midazolam is used in procedures to produce exactly this.
Z-drugs — zolpidem, zaleplon, eszopiclone	Same receptor complex, not benzodiazepines	Sedation and amnestic effects; the FDA notes patients may not remember complex sleep behaviors	Established for the labeled effects; the evidence base is smaller than for benzodiazepines
Gabapentinoids — gabapentin, pregabalin	α2δ subunit of voltage-activated calcium channels	Sedation, psychomotor slowing, dizziness, ataxia — not amnesia	Established impairment; labeled. Different effect from the sedatives above.
Anticholinergic drugs, including tricyclic antidepressants and paroxetine	Muscarinic blockade	Confusion, delirium; small measured effect on cognitive test scores	Acute effects established; the longer-term cognitive signal is modest and observational
Opioids	Central μ-opioid agonism	Sedation, and 2.5-fold increased odds of delirium in older adults at risk	Established — with the counterweight that untreated severe pain also causes delirium

The effects are additive and the list hides that. A resident on temazepam at night, amitriptyline for pain and gabapentin for neuropathy is carrying three separate routes to cognitive impairment at once. Each prescription was reasonable. No single line looks responsible for the result. This is exactly why the Beers Criteria set a threshold for central nervous system polypharmacy — three or more CNS-active medications — as a property of the whole list rather than of any drug on it. In 211,783 long-stay US nursing home residents aged 65 and over, 23.2% met it.

References

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2. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine. 2021;17(2):255–262. PMID 33164742 · DOI 10.5664/jcsm.8986.
3. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2017;13(2):307–349. PMID 27998379 · DOI 10.5664/jcsm.6470.
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6. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005;331(7526):1169. PMID 16284208 · DOI 10.1136/bmj.38623.768588.47.
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8. Parke-Davis, Division of Pfizer Inc. NEURONTIN (gabapentin) capsules, tablets and oral solution — FDA-approved prescribing information. DailyMed, U.S. National Library of Medicine. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee9ad9ed-6d9f-4ee1-9d7f-cfad438df388.
9. U.S. Food and Drug Administration. Certain Prescription Insomnia Medicines: New Boxed Warning — Due to Risk of Serious Injuries Caused by Sleepwalking, Sleep Driving and Engaging in Other Activities While Not Fully Awake. Drug Safety Communication, April 30, 2019. fda.gov. 2019. https://www.fda.gov/safety/medical-product-safety-information/certain-prescription-insomnia-medicines-new-boxed-warning-due-risk-serious-injuries-caused.
10. Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Internal Medicine. 2019;179(8):1084–1093. PMID 31233095 · DOI 10.1001/jamainternmed.2019.0677.
11. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing. 2011;40(1):23–29. PMID 21068014 · DOI 10.1093/ageing/afq140.
12. Jung H, Liu SH, Hume AL, et al. The Prevalence of Central Nervous System-Active Polypharmacy in US Nursing Homes. Journal of the American Medical Directors Association. 2026;27(6):106178. PMID 41895707 · DOI 10.1016/j.jamda.2026.106178.
13. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed August 21, 2026. This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.