Antipsychotic Use Has Been Rising in Long-Term Care Homes, But We Can Do Something About It

In long-term care homes, antipsychotic medications can be a little like a fire extinguisher: lifesaving in the right emergency, alarming when used as a doorstop. These drugs have an important place in medicine, especially for conditions such as schizophrenia, bipolar disorder, and certain severe psychiatric symptoms. But in nursing homes and other long-term care settings, they have too often been used for a different purpose: calming residents with dementia-related behaviors when the real problem may be pain, fear, loneliness, understaffing, noise, constipation, boredom, or a care routine that simply is not working.

The issue is not that every antipsychotic prescription is wrong. That would be too simple, and health care is rarely polite enough to be simple. The real issue is inappropriate antipsychotic use in long-term care homes, especially among older adults with dementia. Federal agencies and clinical organizations have warned for years that these medications can increase the risk of serious harm in older adults, including stroke, falls, cognitive decline, and death. Meanwhile, recent oversight reports have raised concerns that some facilities may still use antipsychotics as chemical restraints or hide their use behind questionable diagnoses.

The good news? We are not helpless. Families, physicians, nurses, pharmacists, administrators, regulators, and direct care workers can reduce unnecessary antipsychotic use while still protecting residents, staff, and other patients. The solution is not “never medicate.” The solution is better assessment, better staffing, better dementia care, better monitoring, and a culture that asks, “What is this resident trying to tell us?” before reaching for the prescription pad.

Why Antipsychotic Use in Long-Term Care Homes Matters

Antipsychotics affect brain chemicals such as dopamine and serotonin. They can help manage hallucinations, delusions, mania, severe agitation, and psychosis. In some situations, they may prevent harm and relieve extreme distress. However, older adultsespecially those living with Alzheimer’s disease or other forms of dementiaare more vulnerable to side effects.

Many residents in long-term care homes have complex medical needs. They may have dementia, chronic pain, hearing loss, depression, infection, poor sleep, mobility limitations, or a history of trauma. When a resident shouts, resists bathing, paces, cries, strikes out, refuses food, or repeatedly asks to “go home,” the behavior is often a message. Unfortunately, the message is not always translated correctly. Instead of asking whether the person is in pain, frightened, overstimulated, or confused, busy facilities may treat the behavior itself as the problem.

That is how medication can become a shortcut. And like most shortcuts in health care, it may lead directly into a pothole wearing a lab coat.

The Numbers Show ProgressAnd a Warning Sign

The United States has made meaningful progress in reducing antipsychotic use in nursing homes. CMS launched the National Partnership to Improve Dementia Care in Nursing Homes to promote person-centered care and non-drug approaches. CMS data show that antipsychotic use among long-stay nursing home residents declined substantially from the 2011 baseline. But the problem has not disappeared.

CMS tracks the percentage of long-stay nursing home residents receiving antipsychotic medications, excluding residents with certain diagnoses such as schizophrenia, Huntington’s disease, or Tourette’s syndrome. While national rates have fallen compared with earlier years, recent data and policy discussions show that use remains significant and varies widely by state and facility. Some homes do excellent dementia care. Others still appear to reach for medication too quickly.

Oversight reports from the U.S. Department of Health and Human Services Office of Inspector General have also raised serious concerns. Investigations found examples of residents with dementia receiving antipsychotics to manage behavior for staff convenience, as well as cases where schizophrenia diagnoses may have been used inappropriately to mask antipsychotic use. That matters because some quality measures exclude residents with schizophrenia, which can create a dangerous incentive if oversight is weak.

Why Antipsychotics Are Risky for Residents With Dementia

The FDA requires strong safety warnings for antipsychotics used in older adults with dementia-related psychosis. These medications are associated with increased mortality in this population and are generally not approved to treat dementia-related psychosis. The Alzheimer’s Association also cautions that antipsychotics should be considered only with extreme care and should not be used simply to sedate or restrain a person with dementia.

Common Risks Include

Potential harms can include drowsiness, dizziness, falls, worsening confusion, movement problems, low blood pressure, stroke, heart rhythm issues, and increased risk of death. A resident who is already frail may become less mobile after sedation. Less mobility can lead to pressure injuries, pneumonia, blood clots, loss of strength, and a faster decline in independence.

There is also a dignity issue. A person with dementia is still a person with preferences, memories, habits, fears, and needs. Using a powerful drug to silence distress without understanding the cause is not care; it is a mute button. And human beings are not televisions, even on days when everyone wishes life came with a remote control.

When Antipsychotics May Be Appropriate

A balanced conversation must acknowledge that antipsychotics are sometimes appropriate. A resident may be experiencing terrifying hallucinations, severe paranoia, violent aggression, mania, or extreme distress that does not respond to non-drug interventions. In those cases, medication may be clinically justified, especially when there is a risk of serious harm to the resident or others.

The key is not to ban the medicine. The key is to use it carefully. Best practice means identifying a specific target symptom, documenting the reason for use, discussing risks and benefits with the resident or representative, starting with the lowest effective dose, monitoring side effects, and reassessing often. If the medication is not helping, it should not remain on the chart like an old refrigerator magnet.

What Causes Overuse in Long-Term Care Homes?

1. Understaffing and Time Pressure

Many long-term care teams are stretched thin. When one aide is helping multiple residents at once, a resident who repeatedly calls out or resists care may be seen as a workflow problem instead of a person in distress. Better staffing does not solve every dementia care challenge, but poor staffing makes nearly every challenge harder.

2. Lack of Dementia Training

Dementia changes communication. A resident may not be able to say, “My hip hurts,” “I am scared of the shower,” or “That hallway is too loud.” Instead, they may yell, push away a caregiver, or refuse care. Staff trained in dementia care are more likely to look for triggers and less likely to label the resident as “difficult.”

3. Environmental Triggers

Bright lights, loud televisions, rushed meals, cold bathrooms, unfamiliar caregivers, cluttered hallways, and confusing routines can all increase agitation. Sometimes the “treatment” is not a pill. It is a quieter dining room, warmer towels, a familiar song, better pain control, or scheduling bathing at a time when the resident is usually calm.

4. Poor Medication Review

Residents may arrive at a facility already taking antipsychotics. Without regular review, temporary prescriptions can become permanent. Pharmacists and medical directors play a critical role in identifying unnecessary psychotropic medications, recommending gradual dose reductions when appropriate, and ensuring the care plan matches the resident’s current condition.

Non-Drug Approaches Should Come First

Clinical guidelines consistently recommend nonpharmacologic interventions as the first-line approach for many behavioral and psychological symptoms of dementia. These approaches are not magic tricks. They require patience, observation, teamwork, and documentation. But they can reduce distress without adding medication risks.

Find the Trigger Before Treating the Behavior

Every behavior has context. If a resident becomes agitated every evening, the team should ask what changes at that time. Is the unit louder? Is the resident tired? Is pain worse? Is hunger an issue? Is the person missing a long-standing routine, such as calling a spouse after dinner?

Use Person-Centered Care

Person-centered care means learning the resident’s history and preferences. A former teacher may enjoy helping “organize papers.” A retired mechanic may calm down when given safe objects to sort. A lifelong gardener may respond beautifully to plants, sunlight, and a few minutes outside. These are not cute extras. They are clinical tools with personality.

Try Music, Movement, and Meaningful Activity

Music, art, gentle exercise, pet visits, spiritual support, hand massage, sensory items, and familiar routines can help reduce agitation for some residents. Not every intervention works for every person. The goal is to build a care plan around the individual rather than forcing the individual into a generic schedule.

Treat Pain, Infection, Sleep Problems, and Constipation

Before assuming a behavior is psychiatric, staff should check common medical causes. Pain is often under-recognized in dementia. Constipation can make anyone cranky enough to write a strongly worded letter to gravity. Urinary symptoms, dehydration, poor sleep, medication side effects, hunger, and sensory impairment can all contribute to agitation.

What Families Can Do

Families are not powerless. If your loved one lives in a long-term care home and is prescribed an antipsychotic, ask clear, calm questions. What symptom is being treated? What non-drug approaches were tried first? What are the risks and benefits? How will staff measure whether the drug is working? When will the medication be reviewed? Is there a plan for gradual dose reduction if symptoms improve?

Families can also share information that staff may not know. Does Mom hate showers but love sponge baths? Did Dad always become restless before dinner? Does your aunt calm down with gospel music, old baseball games, or folding towels? These details may sound small, but in dementia care, small details can do big work.

What Long-Term Care Homes Can Do

Build a Strong Antipsychotic Review Process

Every facility should have a routine process for reviewing antipsychotic use. This includes checking the diagnosis, target symptoms, dose, duration, consent, side effects, and attempted alternatives. Medical directors, consultant pharmacists, nurses, and frontline staff should all be involved.

Train Staff to Decode Behavior

Training should move beyond “manage behaviors” and teach staff how to understand communication in dementia. A resident who refuses care is not automatically being stubborn. The person may be cold, embarrassed, confused, afraid, or in pain. The care approach should change before the medication list grows.

Improve Staffing and Consistency

Consistent assignment helps residents recognize caregivers and helps caregivers understand residents. When staff know a resident well, they notice subtle changes earlier and can often prevent escalation. Stability is medicine too; it just does not come in a blister pack.

Make Data Visible

Facilities should track antipsychotic use, falls, hospital transfers, gradual dose reductions, behavioral incidents, and family concerns. Data should not be used to shame staff. It should be used to ask better questions and improve systems.

What Regulators and Policymakers Can Do

Regulators should continue to monitor antipsychotic use while improving the accuracy of reporting. Quality measures must be strong enough to discourage misuse but smart enough not to punish appropriate, carefully documented clinical care. Oversight should pay special attention to sudden increases in schizophrenia diagnoses, facilities with unusually high antipsychotic rates, and homes with weak documentation of non-drug interventions.

Policy should also support the conditions that make better dementia care possible: adequate staffing, dementia-specific training, consultant pharmacist accountability, medical director engagement, transparent quality data, and family education. We cannot ask nursing homes to reduce unnecessary antipsychotics while ignoring the workforce crisis that often drives shortcut care.

A Practical Framework: Ask Before You Prescribe

A useful approach is to ask five questions before starting or continuing an antipsychotic:

• What exactly is the target symptom? “Agitation” is too vague. Describe the behavior, timing, severity, and risk.
• What might be causing it? Check pain, infection, constipation, sleep, hunger, fear, trauma, overstimulation, and medication side effects.
• What non-drug approaches have been tried consistently? One attempt at music therapy during a fire drill does not count.
• Is there a serious risk of harm or extreme distress? Medication may be appropriate when safety or severe suffering is at stake.
• When will we reassess? Every prescription should have a review plan, monitoring plan, and possible exit ramp.

Experiences From the Front Line: What Better Care Can Look Like

In many long-term care homes, the most successful reductions in antipsychotic use do not begin with a dramatic announcement. They begin with a staff member noticing a pattern. A resident becomes upset every afternoon. A nurse realizes the timing matches a shift change, when the hallway gets noisy and unfamiliar faces appear. The team moves the resident to a quieter area, offers a snack, plays familiar music, and assigns a consistent aide during that transition. The “behavior” decreases. No new medication is needed. Nobody throws confetti, but honestly, they should.

Another common experience involves bathing. Bathing can be frightening for a person with dementia. The room may feel cold. The sound of running water may be startling. Being undressed by someone unfamiliar may feel threatening. A resident who hits or screams during bathing may be labeled aggressive, when the real message is, “I do not feel safe.” A better approach might include warming the bathroom, explaining each step slowly, using towels for modesty, offering a choice between shower and sponge bath, scheduling care at the resident’s best time of day, or having a trusted caregiver assist. When the care plan respects the person, resistance often drops.

Food and hydration can also change behavior. A resident who wanders into other rooms may not be “intrusive”; they may be hungry, thirsty, or searching for something familiar. One facility team discovered that a resident who became restless before dinner had spent decades setting the table for her family. Staff gave her napkins to fold and a safe role in preparing the dining area. Her anxiety eased because the activity matched her identity. She did not need to be shut down. She needed to be useful.

Families often provide the missing puzzle piece. A son may tell staff that his father was a night-shift worker for 40 years and never slept well at night. A daughter may explain that her mother becomes distressed around men because of past trauma. A spouse may know that a certain hymn, baseball team, perfume, prayer, or phrase brings comfort. These details are not sentimental decorations. They are dementia care intelligence.

Frontline caregivers also need support. It is easy to say “use non-drug interventions” from a conference room with coffee and a working printer. It is harder at 7:15 p.m. when two call lights are blinking, one resident is trying to stand without help, another is crying, and the medication cart appears to have been designed by a puzzle villain. If we want fewer unnecessary antipsychotics, we must give staff the time, training, and backup to do the slower, better thing.

The best experiences show that reducing antipsychotic use is not about blaming nurses, doctors, families, or facilities. It is about changing the default question. Instead of asking, “How do we stop this behavior?” we ask, “What is causing this distress, and how can we help?” That shift turns dementia care from control into communication. It protects residents from unnecessary risk while still allowing medication when symptoms are severe, dangerous, or deeply distressing.

Conclusion: We Can Reduce Harm Without Ignoring Suffering

Rising or persistent antipsychotic use in long-term care homes is a warning sign, not a mystery. These medications may be necessary in carefully selected situations, but they should never become a substitute for adequate staffing, careful assessment, pain treatment, dementia training, meaningful activity, or human patience.

Residents with dementia deserve care that sees the person behind the symptom. Families deserve honest conversations. Staff deserve training and support. Physicians and pharmacists deserve systems that help them prescribe wisely. Regulators deserve accurate data. And every resident deserves the chance to be comforted before being chemically quieted.

We can do something about antipsychotic overuse in long-term care homes. In fact, we already know many of the solutions. The work now is to make them normal, measurable, funded, and expectedbecause good dementia care should not depend on luck, guesswork, or whether someone on the evening shift happens to know that Mr. Johnson calms down when the Yankees are on.