Objective: Anticholinergic medications (ACH) have clinical benefits but also impair cognitive function in older adults and may counteract benefits of cholinesterase inhibitors (CHI) in Alzheimer's and other dementias. Prevalence of ACH use and concomitant ACH and CHI use among Indiana Medicaid recipients in nursing homes with dementia was determined. Methods: A retrospective cross-sectional analysis of Indiana Medicaid claims and enrollment files identified persons 65 y/o or older with dementia who took CHI anytime in 2004 and were Medicaid-eligible and in nursing homes continuously in 2004. Dementia was identified using 26 ICD-9 diagnosis codes determined in a prior study as specific for dementia. To exclude persons with just a trial of CHI, only persons receiving a second CHI prescription within 30 days of the end of the indicated days-supply of a prior CHI prescription were classified as CHI users. Only users of drugs identified in published reports as having clinically significant ACH adverse effects (Level 2) or markedly ACH adverse effects (Level 3) were classified as ACH users. Concomitant use was defined as overlap in periods covered by CHI and ACH supply. Days of concomitant use and ACH activity levels also were examined. Results: The sample of 3251 individuals had a mean age of 83 years, was 75% female and, 89% white. Among these, 1,888, 58.07%, (95% CI=56.38–59.77) received an ACH some time during the year and 1519, 46.72% (95% CI=45.01–48.44) received an ACH concomitantly with CHI. Among concomitant users, mean number of days of concomitant use was 158.96 days (95% CI=152.61–165.31) and a majority, 58.13% (95% CI=55.65–60.61) received a Level 3 ACH concomitantly with CHI. Conclusion: Concomitant ACH and CHI use was high among nursing home residents with dementia. Assessing opportunities for alternatives might lead to strategies for tackling this therapeutic dilemma.