There is a quiet but consequential debate underway in Washington, and most families with a loved one in memory care have no idea it is happening.
At the center of the debate is a question that sounds technical but is deeply human: when a person with dementia becomes distressed, frightened, combative, restless, or hard to care for, should the system respond first with medication or with investigation? For decades, nursing homes have been under pressure to reduce the use of antipsychotic drugs in residents with dementia because those drugs can calm behavior, but they can also increase the risk of death, stroke, falls, pneumonia, and profound sedation. The issue has never been whether these medications should be banned. The issue is whether they are being used as careful treatment for the few who truly need them — or as chemical restraint for the many whose distress is inconvenient, misunderstood, or poorly investigated.
That distinction matters because dementia care sits at the intersection of medicine, staffing, regulation, and human dignity. A resident who is pacing may be anxious, in pain, constipated, searching for a familiar face, or reacting to an environment that feels unsafe. A resident who resists bathing may not be “aggressive” so much as frightened, cold, embarrassed, or unable to understand what is happening. Medication may sometimes be necessary, but it can also mask the very clues caregivers need in order to help. That is why federal quality measures were created in the first place: not to second-guess every prescription, but to prevent a vulnerable population from being quietly sedated for the convenience of an overwhelmed system.
In early March 2026, the Centers for Medicare & Medicaid Services confirmed to Skilled Nursing News that it is “actively reviewing” the federal quality measure that tracks antipsychotic use in nursing homes — the same measure that, for more than a decade, has helped cut prescribing by roughly a third and now sits near a reported 17 percent nationally. The review, first surfaced by The Washington Post, comes after lawmakers directed the agency to draw a sharper line between “appropriate” and “inappropriate” prescribing, and after an industry-backed coalition argued that the current rules unfairly penalize facilities for treating residents who genuinely need these medications.
On its face, that sounds reasonable. Nobody — not the providers, not the advocates, not the regulators — wants to deny a resident a medication that legitimately helps. The trouble is what tends to ride in under the banner of “balance.” Easing a metric can quietly become permission to ease the practice the metric was built to discourage. And in this corner of medicine, the practice in question has a long and well-documented history of harm.
What these drugs were never meant to do
Antipsychotics were developed primarily for serious psychiatric illness — especially psychotic and manic disorders. They were not designed as a general tool for making dementia care easier, and most antipsychotic use in dementia care has historically been off-label.
In 2005, the U.S. Food and Drug Administration placed a boxed warning on these medications for older adults with dementia-related psychosis after clinical trials showed a meaningfully higher risk of death — about 1.6 to 1.7 times higher than placebo. Their use has also been associated with elevated risks of stroke, falls, pneumonia, and accelerated cognitive decline.
Those are the clinical risks. There is also a quieter harm that no chart fully captures: the loss of voice, presence, and personhood that can come with sedation. A person who is “calmer” on these drugs is sometimes simply a person who has been turned down.
What is striking is how often medication is reached for in response to something that may not be a disease symptom at all. The clinical vocabulary — “agitation,” “aggression,” “wandering,” “behavioral and psychological symptoms of dementia” — can too easily frame distress as pathology to be suppressed. But a resident who calls out may be frightened. One who resists care may feel exposed, rushed, or unheard. One who paces the hallway may be looking for a familiar face, a sense of purpose, or a way out of a room that no longer feels like theirs.
These are not malfunctions. They are communication. And often the message is physical: constipation, a urinary tract infection, dental pain, hunger, thirst, loneliness, overstimulation, undertreated pain — the kind of distress that sedation can silence instead of solve.
That is why the metric matters: not because every prescription is wrong, but because without pressure, the system can too easily confuse quiet with care.
The case that we already know how to do better
This reframing is not new, and it is not mine. The geriatrician Dr. G. Allen Power has spent more than two decades arguing, in books such as Dementia Beyond Drugs and Dementia Beyond Disease, that we need to “change our minds about those whose minds have changed.”
His contention is that distress in dementia is often the predictable result of an environment that fails to meet basic human needs — what the Eden Alternative frames as seven domains of well-being: identity, connectedness, security, autonomy, meaning, growth, and joy. When those needs are supported, Power argues, distress often falls away without a prescription.
One of the most-cited examples comes out of Arkansas. As Power has described it, a well-being-focused effort led by his colleague Dr. Angela Norman began as a small 2016 pilot in which three of four homes cut antipsychotic use by more than 60 percent in about six months. That work reportedly expanded across more than 100 long-term care homes, eventually driving average use down to roughly 4.6 percent without compromising resident safety.
That is one operator’s network rather than a randomized trial, and it should be read as such. But it is not an isolated result. The WHELD cluster-randomized trial of person-centered care training found improvements in quality of life, agitation, and neuropsychiatric symptoms. A collaborative-care model piloted in three Indiana skilled nursing facilities reported a 68 percent reduction in antipsychotic use with “no noted harms or clinical decline.”
The throughline is consistent. When you invest in people — staff education, time to build relationships, environments designed to lower distress rather than provoke it — the drugs become far less necessary.
The harder, more honest part
Here is where I want to be fairer to the other side than the loudest voices in this debate usually are, because the case for changing the metric is not pure cynicism.
The current measure really is flawed. CMS’s own revisions have made it more complex, not less: a new “hybrid” method blends survey data with Medicare and Medicaid claims, and regulatory experts have warned it could distort facility star ratings in ways that do not reflect actual care quality.
The measure also has to account for legitimate FDA-approved indications. Brexpiprazole was approved in 2023 for agitation associated with dementia due to Alzheimer’s disease. More recently, other non-antipsychotic options have entered the conversation as well. A facility should not be punished simply because a physician used an approved treatment thoughtfully, with informed consent, close monitoring, and a plan to reassess.
There are also residents whose distress genuinely cannot be managed any other way, and whose safety — or a caregiver’s — may depend on medication. Dr. Michael Steinman, who co-chaired the American Geriatrics Society’s guidelines on alternatives to these drugs, has put it plainly: some people do need them. Just far fewer than currently receive them.
So yes: refine the measure. Make it smarter, less punitive for legitimate care, and harder to game. A 2021 Inspector General report found that nursing homes had underreported roughly 12,000 cases and that a third of residents coded as schizophrenic — a diagnosis that exempts a prescription from the metric — had no Medicare service claims to support it. A better measure would close that loophole while still crediting good clinical judgment.
That is reform.
What worries me is the slide from refining the measure to relaxing the expectation. Those are not the same thing, and the system has every incentive to blur them. Staffing shortages are real. Regulatory burden is real. The complexity of dementia care is real. But sedation can become the cheapest possible answer to all three, which is precisely why the guardrails exist.
As resident advocates told The Washington Post, some facilities already lean on medication to compensate for thin staffing and undertrained workers. Loosening the rules makes that path easier, not harder.
Raise the bar
There is one more thing the nursing-home framing misses. Many people arrive at memory care already on these medications — started in a hospital, a community setting, or an overwhelmed family situation — and simply carry that trajectory through the door. Well-being is underrecognized wherever people live, not just in long-term care.
Any family touring a facility, here in San Miguel de Allende or anywhere else, is entitled to ask a direct question:
When my mother is distressed, what do you reach for first?
The right answer is not a drug. It is curiosity, investigation, and the genuine care it takes to find and treat the root cause.
Families should also be told plainly why a medication is being used, what non-drug causes were ruled out, what risks the boxed warning describes, how the team will monitor for harm, and when they will attempt dose reduction. A prescription should not be a destination. It should be a time-limited intervention, used only when necessary, at the lowest effective dose, and with a plan to revisit whether it is still needed.
Overprescribing was never mainly a failure of individual doctors or nurses. It is what you get from a system that rewards the quick fix and reads humanity as pathology. The fix is not to lower what we ask of that system.
If we are serious about dementia care, the goal cannot be to manage behavior more efficiently. It has to be to understand the person more deeply — and to build the staffing, training, and environments that make understanding possible.
The question on the table in Washington is narrow and technical. The question underneath it is not. Before we agree to loosen anything, we should be honest about what we would be loosening it for.
Sources and further reading:
- Centers for Medicare & Medicaid Services and Skilled Nursing News reporting on the March 2026 review; The Washington Post reporting on the federal nursing-home antipsychotic measure
- U.S. FDA boxed warning on antipsychotic use in older adults with dementia-related psychosis
- FDA approval of brexpiprazole for agitation associated with dementia due to Alzheimer’s disease; Office of Inspector General report on antipsychotic underreporting
- Dr. G. Allen Power, Dementia Beyond Drugs and Dementia Beyond Disease
- Dr. Angela Norman and University of Arkansas for Medical Sciences; the WHELD cluster-randomized trial; and the GuideStar Eldercare/JAMDA collaborative-care study.
(Note: About Us, and if relevant, a reference bibliography, related books, videos, and apps can be found at the end of this article.)
Disclaimer: As a Senior Health Advocacy Journalist, I strive to conduct thorough research and bring complex topics to the forefront of public awareness. However, I am not a licensed legal, medical, or financial professional. Therefore, it is important to seek advice from qualified professionals before making any significant decisions based on the information I provide.
Copyright: All text © 2026 James M. Sims and all images exclusive rights belong to James M. Sims and Midjourney unless otherwise noted.
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