Mrs. Rivera, your 76-year-old patient, worries her memory isn’t what it used to be. A friend suggested ginkgo, and she saw something online about lion’s mane. Now she’s wondering if she should start taking something, just in case.

This situation is increasingly common. Older adults are searching for ways to maintain cognitive health, and the supplement market is eager to meet that demand. Products marketed as nootropics go by many names: brain boosters, memory enhancers, cognitive support formulas, neuroprotective supplements, even “longevity stacks.” They range from herbal capsules to prescription medications used off-label for attention or memory. Some patients want to treat early cognitive symptoms. Others are simply hoping to stay sharp as they age.

What, if anything, should we actually recommend? And just as important, what should we steer patients away from? Let’s take a closer look.

What counts as a nootropic?
The term nootropic was originally coined in the 1970s to describe compounds like piracetam, a drug developed in Europe and sometimes used off-label for memory problems or after stroke. Although piracetam never gained FDA approval in the US, it’s still widely referenced in research on cognitive enhancers (Cicero AFG et al, Pharmacol Res 2018;130:204–212). Today, the descriptor of nootropic is used more broadly (often by marketers) and may include prescription medications, supplements, and lifestyle strategies aimed at boosting brain function.

This article focuses on agents patients are most likely to ask about: prescription medications with cognitive effects and common over-the-counter supplements promoted for brain health.

Prescription-based agents

Stimulants
Stimulants such as modafinil, methylphenidate, and amphetamine salts can improve attention and alertness. There’s limited evidence they enhance cognitive performance in healthy older adults. Some studies show transient benefits in vigilance or processing speed, but they come with caveats: misuse potential, insomnia or agitation, and cardiovascular risks, particularly in older adults with comorbidities.

A meta-analysis found that stimulants had modest effects on attention in younger adults, but there were limited data in older adults, where risks may outweigh benefits (Repantis D et al, Pharmacol Res 2010;62(3):187–206). These medications may be useful in select cases, such as apathy in depression or early dementia, but they are not first-line interventions for cognitive aging.

Cholinesterase inhibitors and memantine
Donepezil and other cholinesterase inhibitors are FDA approved for Alzheimer’s disease (AD) and sometimes used off-label for mild cognitive symptoms. However, in cognitively normal adults, evidence of benefit is lacking. In addition, side effects such as nausea, bradycardia, and insomnia are common and clinically meaningful in older adults.

A Cochrane review found that cholinesterase inhibitors had no meaningful cognitive benefit in older adults without dementia (Birks JS and Harvey RJ, Cochrane Database Syst Rev 2018;6(6):CD001190). Memantine, an NMDA receptor antagonist, has similarly limited evidence outside of moderate to severe AD. Bottom line: These drugs should not be used for prevention or nonspecific memory complaints.

Supplements and botanicals
Patients often prefer “natural” options and may already be taking supplements by the time they bring them up. Here’s what to know.

Apoaequorin (Prevagen)
While apoaequorin is heavily marketed for memory, there is no convincing evidence it improves cognition in healthy older adults. Support comes mainly from small, industry-funded trials with questionable clinical significance. Marketing claims have drawn regulatory scrutiny.

Ginkgo biloba
Widely promoted for memory enhancement, ginkgo biloba has been tested in multiple trials. It may offer modest benefit in mild cognitive impairment, but it has no consistent effect in cognitively normal adults. It also carries risk of bleeding and drug interactions, especially in patients on anticoagulants or antiplatelets.

A 2018 review concluded that ginkgo had no significant cognitive benefit in healthy aging and raised safety concerns (Cicero et al, 2018). It is not advised for routine use.

Omega-3 fatty acids
Omega-3s (DHA, EPA) support neuronal membrane structure and have anti-inflammatory effects. Findings include small benefits for global cognition in patients with low dietary intake, but no consistent improvement in healthy, well-nourished adults.

Recent reviews suggest limited efficacy but low risk (Hersant H et al, CNS Drugs 2023;37(9):797–817). They can be considered when diet is poor or cardiovascular risk is high.

Curcumin
Curcumin’s anti-inflammatory properties are appealing, but cognitive data are inconsistent. Bioavailability varies widely.

Lithium orotate
Lithium orotate is marketed as a low-dose neuroprotective. Limited data suggest low-dose lithium may slow cognitive decline, but no high-quality trials support lithium orotate. Use caution.

CoQ10
While CoQ10 is important for mitochondrial function, there is no good evidence that it provides any cognitive benefit in non-neurodegenerative populations.

Bacopa monnieri, ashwagandha, lion’s mane

• Bacopa monnieri: Best studied. Meta-analyses show modest, inconsistent improvements in working memory and short-term memory at higher doses (Tiemtad P et al, Phytomedicine 2026;153:157915).
• Ashwagandha: Primarily reduces stress; cognitive benefits are secondary and mixed.
• Lion’s mane: Very limited human data.

Across all three, trials are small and effect sizes are modest. Regulation is loose and potency varies, in addition to occurrences of contamination and adulteration. In short, the marketing claims for these substances often exceed the available data (Cicero et al, 2018).

L-theanine
Found in tea leaves, L-theanine may promote alertness and improve focus when combined with caffeine, but it has no proven effect on memory. It is generally well tolerated, though insomnia or irritability can occur with high doses.

What does help?
The best-supported interventions for preserving cognition are nonpharmacologic:

• Exercise: Regular aerobic exercise and resistance training improves attention and executive function. Exercise stimulates neurogenesis and increases cerebral blood flow (Chen C and Nakagawa S, Ageing Res Rev 2023;86:101868).
• Diet: A Mediterranean or MIND diet supports vascular and mitochondrial health. Recommend a diet rich in fish, leafy greens, berries, nuts, legumes, olive oil, and other healthy fats. Just as important: Limit ultra-processed foods. Higher intake is linked to worse cognitive outcomes, even after accounting for overall diet quality (Gomes Gonçalves N et al, JAMA Neurol 2023;80(2):142–150).
• Sleep: Getting a good night’s sleep helps with memory consolidation and reduces the risk of cognitive decline.
• Cognitive and social engagement: Activities like learning a new language or volunteering promote neuroplasticity.
• Risk factor management: Hypertension, diabetes, depression, and hearing loss are all linked to cognitive decline. Strategies to control these conditions are consistently more effective than any supplement or off-label prescription.

How to talk to patients
Start by clarifying the patient’s goals. Are they treating a specific symptom or hoping to prevent decline? Then frame the conversation with transparency and offer alternatives with stronger evidence. You might consider saying something like, “Some supplements sound promising, but most haven’t shown meaningful benefits. We have better data supporting exercise, a healthy diet, and staying socially and mentally active.”

If patients still want to try a supplement, steer them toward options with relatively low risk and modest evidence, like omega-3s. Recommend brands verified by third parties such as USP to reduce contamination risks. Let patients know that supplements are often expensive and not covered by insurance.

Safety and monitoring
Watch for:

• Polypharmacy: Supplements may not appear on medication lists unless you ask about them
• Drug interactions: Ginkgo, ashwagandha, and others can increase bleeding risk or affect blood pressure and thyroid levels
• Unrealistic expectations: Some patients may delay effective treatments or lifestyle changes

After reviewing Mrs. Rivera’s medication list, you ask about her routine. She admits she hasn’t exercised since before the pandemic. You recommend a weekly tai chi class and review strategies for sleep and diet. She decides to skip the ginkgo and focus on practical changes she can stick with.

Carlat Verdict: Nootropic supplements are popular but unproven. Prescription stimulants and dementia medications offer limited value outside their approved uses. The most effective ways to support cognitive health in older adults are physical activity, a nutrient-rich diet, mental and social engagement, and treatment of comorbidities.