Gabapentin Safety in Older Adults at Risk for Dementia
Gabapentin can be prescribed to older adults at risk for dementia when used for appropriate indications like neuropathic pain, but recent high-quality evidence demonstrates a concerning association between gabapentin use and increased dementia risk, particularly with prolonged use and in younger-old adults, requiring careful risk-benefit assessment and avoidance of high-risk drug combinations. 1, 2
Critical Evidence on Dementia Risk
Recent Population-Based Findings
The most recent and robust evidence reveals a troubling association:
A 2025 retrospective cohort study of 26,416 adults with chronic low back pain found that six or more gabapentin prescriptions increased dementia risk by 29% (RR: 1.29; 95% CI: 1.18-1.40) and mild cognitive impairment risk by 85% (RR: 1.85; 95% CI: 1.63-2.10). 2
Non-elderly adults aged 18-64 prescribed gabapentin had over twice the risk of dementia (RR: 2.10; 95% CI: 1.75-2.51) compared to those not prescribed gabapentin, with risk increasing further with prescription frequency. 2
A 2023 Taiwanese population study of 206,802 patients demonstrated that gabapentin or pregabalin exposure increased dementia risk with a hazard ratio of 1.45 (95% CI: 1.36-1.55), with risk escalating at higher cumulative doses. 1
The dementia risk was paradoxically highest in younger patients (age <50) with a hazard ratio of 3.16 (95% CI: 2.23-4.47), suggesting particular vulnerability in this population. 1
Appropriate Use Guidelines
When Gabapentin Is Acceptable
Despite dementia concerns, gabapentin remains appropriate for specific indications:
Gabapentin is explicitly recognized as appropriate for neuropathic pain management in older adults, including those with limited life expectancy, according to STOPPFrail 2021 criteria. 3
For neuropathic pain in older adults, gabapentin should be initiated at 100-200 mg/day (significantly lower than standard adult doses of 900-3600 mg/day) with incremental dose escalation. 3, 4
The American Geriatrics Society identifies gabapentin as a first-line therapy for chronic neuropathic pain, with pregabalin potentially preferred due to easier titration and more predictable pharmacokinetics. 3, 4
Critical Safety Restrictions
The American Geriatrics Society explicitly recommends avoiding concurrent use of opioids with gabapentinoids, as this combination increases risk of respiratory depression and death in older adults, with particular emphasis on elderly patients with dementia. 5
Concurrent use of three or more CNS-active drugs—including gabapentin combined with antidepressants, antipsychotics, benzodiazepines, or other antiepileptics—significantly increases fall risk and should be avoided whenever possible in elderly patients with dementia. 5
Practical Prescribing Algorithm for Older Adults
Pre-Prescription Assessment
Document all current CNS-active medications and discontinue or minimize these before adding gabapentin, ensuring the patient is not taking opioids concurrently. 5
Assess renal function, as gabapentin requires dose adjustment in moderate or greater renal impairment; use the lowest starting doses (100 mg/day) in this population. 3
Consider pregabalin as an alternative first-line option due to linear pharmacokinetics, simpler twice-daily dosing versus gabapentin's three-times-daily regimen, and faster titration capability. 4
Dosing Strategy
Start with gabapentin 100-200 mg/day in older adults, with the lowest doses (100 mg/day) appropriate for those with moderate or greater renal impairment. 3
Implement dose escalation incrementally at intervals long enough to monitor for somnolence, dizziness, mental clouding, and fall risk—side effects that are particularly problematic in older patients. 3
Effective doses in older adults may be lower than the typical 900-3600 mg/day range seen in controlled studies; titrate to benefit or until side effects emerge. 3
Ongoing Monitoring
Reassess the need for gabapentin continuation every 3 months, attempting dose reduction or discontinuation if symptoms have stabilized, to minimize long-term adverse effects including potential cognitive decline. 5
Monitor specifically for increased fall risk, respiratory depression (especially if any opioid co-exposure occurs), pneumonia, cognitive impairment, and functional decline. 6
In patients under age 65, exercise heightened vigilance given the disproportionately elevated dementia risk observed in this population with gabapentin exposure. 1, 2
Evidence for Behavioral Symptoms in Dementia
Limited and Insufficient Data
Currently, sufficient evidence for recommending gabapentinoids for treatment of behavioral and psychological symptoms of dementia (BPSD) is not available, with only one RCT (pregabalin), systematic reviews, and case series predominantly reporting good efficacy and tolerability. 6
A 2008 review found only 11 case reports, 3 case series, and 1 retrospective chart review supporting gabapentin for BPSD, with no controlled studies published, limiting support for this off-label use. 7
Two case reports questioned the appropriateness of gabapentin for agitation in dementia with Lewy bodies, suggesting it may not be suitable for all dementia subtypes. 7
Critical Pitfalls to Avoid
Never combine gabapentin with opioids in elderly dementia patients due to synergistic respiratory depression risk. 5
Avoid polypharmacy with multiple CNS-active agents, as this dramatically increases fall and fracture risk in older adults. 5, 6
Do not prescribe gabapentin for BPSD as a first-line agent; non-pharmacologic interventions and medications with better evidence (cholinesterase inhibitors for neuropsychiatric symptoms) should be prioritized. 8, 6
Recognize that gabapentin has scant evidence for off-label uses, withdrawal is likely after as few as three weeks of treatment, and the drug is the tenth-most prescribed medication in the United States with growing abuse potential. 9
Be aware that gabapentin's increased fall risk, respiratory depression, pneumonia risk, and possible atrial fibrillation represent specific geriatric hazards beyond the dementia association. 6
Risk-Benefit Decision Framework
When neuropathic pain requires treatment in an older adult at risk for dementia:
Prioritize topical therapies (lidocaine, diclofenac, high-concentration capsaicin) due to low systemic absorption and high safety profile. 3
If systemic therapy is needed, consider duloxetine (60 mg/day) as an alternative SNRI with evidence for neuropathic pain. 4
If gabapentin is chosen, use the lowest effective dose for the shortest duration necessary, with mandatory 3-month reassessments for continuation. 3, 5
In patients under age 65, exercise extreme caution given the 2-3 fold increased dementia risk observed with gabapentin exposure in this population. 1, 2
Document the specific indication (neuropathic pain), confirm absence of opioid co-prescription, minimize other CNS-active drugs, and establish a monitoring plan for cognitive function and falls. 5