Choosing a Facility
Antipsychotic Drugs in Nursing Homes: What Families Should Know
What Should Families Know About Antipsychotics in Nursing Homes?
Antipsychotics in nursing homes carry an FDA boxed warning: older adults with dementia-related psychosis who take them face a higher risk of death. Federal rules allow these drugs only for a diagnosed condition documented in the record, with non-drug approaches and dose reductions tried, and CMS tracks each home's use. In August 2026 data, the national median was 13.37% of long-stay residents receiving an antipsychotic.
If your parent is living with dementia, there’s a real chance that at some point a nursing home doctor will suggest an antipsychotic drug. These medicines have a place, but for people with dementia they carry serious risks, and federal rules set strict limits on how nursing homes may use them. Knowing those rules lets you ask the right questions before a prescription starts, not after.
Antipsychotics in Nursing Homes: What Families Need to Know First
- The FDA’s strongest warning applies. Antipsychotic labels carry a boxed warning that older adults with dementia-related psychosis treated with these drugs face an increased risk of death.
- Federal rules limit their use. A nursing home may give an antipsychotic only for a specific diagnosed condition documented in the record, must try behavioral approaches and gradual dose reductions, and must have a prescriber re-evaluate any as-needed order after 14 days.
- Use has fallen, and CMS tracks it. In August 2026 data, the national median was 13.37% of long-stay residents receiving an antipsychotic in the 2025Q2-2026Q1 measure period. 7,044 homes were below that median.
- You have rights. Your parent, or their legal representative, has the right to be told the risks and benefits first and to refuse.
What the FDA Boxed Warning Says
A boxed warning is the most serious warning the FDA puts on a prescription drug label. For antipsychotics, it covers older adults with dementia-related psychosis. The label for risperidone (Risperdal), one example, explains why:
- In 17 placebo-controlled trials lasting around 10 weeks, mostly of newer “atypical” antipsychotics, people with dementia who took the drug had 1.6 to 1.7 times the risk of death of those taking a placebo.
- Over a typical 10-week trial, about 4.5% of people on the drug died, compared with about 2.6% on placebo.
- Most deaths appeared to be from heart problems, such as heart failure or sudden death, or infections such as pneumonia.
- Observational studies suggest older, “conventional” antipsychotics may also increase the risk of death.
The risperidone label adds a separate warning: in trials of people with dementia-related psychosis, strokes and mini-strokes, some fatal, happened significantly more often than with placebo. And it states plainly that risperidone is not approved to treat dementia-related psychosis.
One drug now has a narrow approval. Brexpiprazole (Rexulti) is FDA-approved to treat agitation associated with dementia due to Alzheimer’s disease. Its label still carries the same boxed warning on increased mortality, and it says the drug is not for as-needed use for that agitation.
None of this means an antipsychotic is never right for a particular person. It means the decision belongs to your parent’s doctor, with the risks laid out clearly to your family, and it should be revisited regularly.
What Federal Rules Allow
Nursing homes that take Medicare or Medicaid must follow federal pharmacy rules in 42 CFR 483.45. Antipsychotics count as psychotropic drugs, along with antidepressants, anti-anxiety drugs and sleep medicines.
| Rule | What it means for your parent |
|---|---|
| No unnecessary drugs | No drug in excessive doses or for too long, without monitoring, without a reason, or despite side effects that call for stopping |
| Diagnosis required | A resident who hasn’t taken psychotropic drugs can’t be started on one unless it’s needed to treat a specific condition diagnosed and documented in the record |
| Dose reductions and behavioral approaches | Residents on psychotropic drugs get gradual dose reductions and behavioral interventions, unless clinically contraindicated, aimed at stopping the drug |
| As-needed limits | An as-needed (PRN) antipsychotic order lasts no more than 14 days and can’t be renewed unless the prescriber evaluates your parent |
| Monthly pharmacist review | A licensed pharmacist reviews every resident’s medicines at least monthly and reports problems to the doctor, medical director and director of nursing |
| No chemical restraints | Your parent has the right to be free from any drug imposed for discipline or staff convenience and not needed to treat medical symptoms |
Your parent also has the right to be told in advance about the risks and benefits of proposed treatment and the alternatives, to choose among them, and to refuse.
Who Takes Part in the Decision
A prescription in a nursing home involves more people than at a doctor’s office, and each one is a place to ask questions:
- The prescriber. The attending physician or another prescribing practitioner orders the drug and must document the diagnosed condition it treats. Your parent has the right to choose their attending physician.
- The pharmacist. A licensed pharmacist reviews your parent’s medicines at least once a month, including the medical chart. Any problem, such as a drug that looks unnecessary, goes in writing to the doctor, the medical director and the director of nursing, and the doctor must record what was done about it.
- The care team. Nurses and aides carry out the behavioral approaches that federal rules require alongside, or instead of, the drug. Ask them what they have tried and what seems to help.
- Your parent and family. Your parent has the right to be told the risks, benefits and alternatives first, to choose, and to refuse. Care plan meetings are where these choices get written down.
If a drug was started during a hospital stay, ask the nursing home team to review whether it is still needed. The federal rules on unnecessary drugs and gradual dose reductions apply to every resident.
Antipsychotic Use Below the National Median: Nursing Homes by State
CMS Care Compare lists 7,044 nursing homes in this group (antipsychotic use below the national median) across 51 states and territories, data from August 2026. Pick a state for its nursing homes, cities and senior care rules.
How CMS Tracks Antipsychotic Use
In 2012, CMS launched the National Partnership to Improve Dementia Care in Nursing Homes. Its first focus was cutting antipsychotic use, but its larger goal is person-centered dementia care and non-drug approaches. CMS reported that between the end of 2011 and early 2017, antipsychotic use among long-stay residents fell 34.1%, from 23.9% to 15.7%, beating its goal of a 30% reduction.
Today, CMS publishes two antipsychotic measures for each home on Care Compare:
- Long-stay: the share of residents who have lived in the home more than 100 days and received an antipsychotic. Since January 2026, CMS has added Medicare and Medicaid claims data to the home’s own assessments. Residents with a history of schizophrenia are excluded, since the drugs are an approved treatment for it.
- Short-stay: the share of newer residents who got an antipsychotic for the first time during their stay.
The long-stay measure is one of the most heavily weighted inputs in the CMS quality star rating. CMS also audits schizophrenia coding, and a home caught miscoding drops to 1 quality star for six months. The star ratings guide explains how the measure feeds the rating.
The 2017 figures and today’s median aren’t measured the same way, so don’t compare them directly. Compare homes with each other using the current measure.
How to Check a Nursing Home’s Rate
For long-stay residents, the national median in the 2025Q2-2026Q1 period was 13.37% receiving an antipsychotic, and 18.11% receiving an anti-anxiety or sleep medicine. A rate well above the median isn’t proof of poor care on its own, but it is a reason to ask the home why.
To compare homes:
- Look up each home on the nursing home finder and compare the antipsychotic measure side by side with the Nursing Home Comparison tool.
- Browse state lists of homes with lower use, such as California, Florida, New York and Texas.
- Read the inspection report for citations about unnecessary drugs or psychotropic medicines. The inspection reports guide shows how.
Questions to Ask Before and After Admission
Medicare’s nursing home checklist includes questions about dementia care and antipsychotics. Bring them to your tour:
- Does the home have dementia care policies that try non-medication approaches first when a resident shows distress? Medicare’s checklist notes that behavioral symptoms are often a way of communicating.
- What share of residents with dementia are currently prescribed an antipsychotic?
- What is the home’s current rate of antipsychotic use?
- Does the home take part in efforts to reduce antipsychotic use?
If your parent already lives in the home, or a new prescription is proposed, ask:
- What specific condition is the drug treating, and is it documented?
- What non-drug approaches were tried first, and what happened?
- When will the dose be reviewed for reduction, and who will tell the family?
- If it’s an as-needed order, when does it expire?
- What side effects should the family watch for, and who should they call?
Ask for these answers at the care plan meeting, and ask the home to call you before any new psychotropic drug is started. The how to choose a nursing home guide has Medicare’s full checklist, and the memory care guide covers dementia-focused settings.
If You’re Worried About a Prescription
Start with the people closest to the decision: the prescriber, the director of nursing and the care team. You can ask for a medication review and for the pharmacist’s latest notes.
If the home doesn’t respond, contact your state’s Long-Term Care Ombudsman, who advocates for residents, or file a complaint with the state survey agency, which inspects nursing homes. The residents’ rights and ombudsman guide explains both. If you believe a drug is being used to sedate your parent for staff convenience, the abuse and neglect warning signs guide covers how to report it. Call 911 if your parent is in immediate danger.
Paying for Nursing Home Care While You Advocate
Your parent’s rights around medicines are the same whoever pays for the stay. Medicare covers only short-term skilled nursing stays; long-term care is paid by Medicaid, private funds, long-term care insurance or veterans’ benefits. The guide to paying for a nursing home and the Medicaid eligibility guide explain each option, and the dementia care options guide compares settings for a person living with dementia.
Frequently Asked Questions
Can a Nursing Home Start an Antipsychotic Without Telling the Family?
Residents have the right to be told in advance about the risks and benefits of proposed treatment and alternatives, and to choose among them, and the right to refuse treatment. Ask the home to tell you before any new psychotropic drug is started.
Are Antipsychotics Ever Approved for Dementia?
One is approved for a specific use. Brexpiprazole (Rexulti) is FDA-approved to treat agitation associated with dementia due to Alzheimer's disease, though its label still carries the boxed warning on increased mortality and says it is not for as-needed use. Other antipsychotics, such as risperidone, state on their labels that they are not approved for dementia-related psychosis.
Why Is Schizophrenia Excluded From the CMS Measure?
CMS's long-stay antipsychotic measure excludes residents with a history of schizophrenia, because the drugs are an approved treatment for it. CMS audits schizophrenia coding, and homes found miscoding it have their quality rating dropped to 1 star for six months.
Is Using a Drug to Keep a Resident Calm a Chemical Restraint?
It can be. Federal rules give every resident the right to be free from chemical restraints imposed for discipline or staff convenience and not required to treat medical symptoms. If you think a drug is being used for convenience, raise it at once with the director of nursing and the Long-Term Care Ombudsman.
How Long Can an As-Needed Antipsychotic Order Last?
No more than 14 days. Under federal rules, an as-needed (PRN) antipsychotic order can't be renewed unless the attending physician or prescribing practitioner evaluates the resident to decide whether the drug is still appropriate. Other as-needed psychotropic orders can be extended past 14 days only if the prescriber documents the reason and a duration.
Where Can I Learn About Alzheimer's Medications?
Drugs that treat Alzheimer's disease itself are a different topic from antipsychotics. Ask your parent's doctor, and see the dementia care options guide for care settings and support.
More on Choosing a Facility
- Choosing a Nursing HomeRatings, inspections, staffing and the questions to ask on a visit
- Star Ratings ExplainedWhat each Care Compare star rating measures and its limits
- Inspection ReportsDeficiencies, scope and severity, fines and where to find reports
- Staffing and TurnoverNurse staffing hours, turnover and the federal staffing data
- Abuse Warning SignsWarning signs, CMS's abuse icon and who to call
- Residents' RightsFederal residents' rights and the free ombudsman program
This guide explains long-term care in plain language from official sources. It isn't medical, legal or financial advice; a doctor, your state Medicaid agency or an elder law attorney can advise on your situation.
Sources
- DailyMed: Risperdal (risperidone) prescribing information, FDA label
- DailyMed: Rexulti (brexpiprazole) prescribing information, FDA label
- CMS: National Partnership to Improve Dementia Care
- CMS fact sheet: National Partnership to Improve Dementia Care achieves goals (October 2, 2017)
- eCFR: 42 CFR 483.45, Pharmacy services
- eCFR: 42 CFR 483.10, Resident rights
- eCFR: 42 CFR 483.12, Freedom from abuse, neglect, and exploitation
- CMS: Nursing Home Five-Star Quality Rating System, Technical Users' Guide (September 2026)
- Medicare.gov: Nursing home checklist
- Medicare.gov: Long-term care
- CMS Provider Data Catalog: Nursing Home Provider Information (August 2026)