The Struggle with Antipsychotic Reduction

by | Apr 1, 2021 | Five Star & Quality, Tool Box Essentials

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Since CMS began to monitor antipsychotic use in 2011, skilled nursing facilities have done well to reduce the use of antipsychotic medications from the original rate of 23.9%. However, over the past few years, the rate has remained around 14%. Some facilities believe they have done everything possible and this 14% represents residents that truly need antipsychotic medications. Is your facility doing all it can to keep antipsychotic use low? What if there is a better approach?

The quality measure that CMS imposes on skilled nursing facilities is formally known as, Percent of Residents Who Received an Antipsychotic Medication.

  • Numerator:  Long-stay residents with a selected target assessment where the following condition is true: antipsychotic medications received
  • Denominator:  Long-stay nursing home residents with a selected target assessment except those with exclusions
  • Exclusions:  Schizophrenia, Tourette’s syndrome, Huntington’s disease

By including antipsychotic use as a quality measure, CMS is attempting to discourage excessive use of this medication type. These medications come with a wide range of adverse effects, including cardiovascular incidences, insulin resistance, and death. CMS encourages the use of patient-specific care planning and interventions to target unique patient behaviors. They share resources that promote the value of planned activities to enrich residents’ lives and create positive experiences. When antipsychotics are required, they suggest using the lowest possible dose for the shortest amount of time possible. These recommendations are consistent with APA guidelines and currently available research evidence. With the National Partnership, CMS offers a wide range of resources that promote the adequate assessment of behavioral factors and non-pharmacologic/supportive treatment options.

Taking Antipsychotic Reduction One Step Further

Antipsychotics work through mechanisms that block dopamine and serotonin. They may not work as well in behavioral symptoms that are not caused by elevated dopamine. For example – schizophrenia, Tourette’s, and Huntington’s disease all have high dopamine levels as part of their pathology, while Alzheimer’s and Parkinson’s diseases already have extremely low dopamine levels.

Antipsychotics have been largely ineffective against agitation and behaviors related to dementia in research studies. Their mild effect on behaviors may be largely due to sedative side effects rather than the medication’s main action.

On the other hand, many alternative therapies such as music, activities, sensory therapy, person-centered therapy, cognitive behavioral therapy, behavioral management, exercise, cognitive stimulation therapy, simulated presence therapy, crisis coregulation, and dementia care mapping have been found to reduce behavioral symptoms in studies involving patients with a dementia diagnosis.


Staff training and support allow for staff interventions that skillfully reduce agitation. Mental health nurses that can develop patient-centered care plans also decreased the need for antipsychotic use. After much research, it is becoming clear that skilled nursing facilities are not utilizing enough alternative therapies to support patients with dementia.  Facilities should ask the question: What new interventions can we use to decrease behaviors without medications?

Additional Resources

MDS 3.0 QM User’s Manual Version 14.0 at

Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia at

National Partnership to Improve Dementia Care in Nursing Homes at

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