Antipsychotics Worsen Behavior in Nursing Home Residents, Especially Those With Dementia: Study

Up to 26 percent of nursing home residents in North America are prescribed antipsychotics, but recent research found that such drugs often add fuel to the fire.

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Placing loved ones in a nursing home is never easy. It’s often a last resort to ensure they get the care they need. However, new research highlights an issue with the use of antipsychotic medications used in these settings.

A recent study of nearly 500,000 nursing home residents in Canada found that prescribing antipsychotics, used to treat behavioral issues and psychosis, may actually be linked to worse behavior.

The study found that almost three-quarters of those prescribed antipsychotic medications experienced increased agitation and irritability.

“Antipsychotics are still used quite commonly in nursing homes to manage behavioral expressions, particularly for residents living with dementia,” Jasmine Travers, an assistant professor at New York University Rory Meyers College of Nursing, told The Epoch Times in an email.

As people age, the likelihood of developing dementia increases. The condition occurs when nerve cells in the brain stop functioning, leading to a gradual decline in the ability to think clearly and perform everyday tasks. This can result in challenging behaviors, such as wandering, refusal of care, or aggression.

In nursing homes, these behaviors are sometimes managed with sedatives or medications used as “chemical restraints,” said Travers, who was not involved in the study. However, this approach raises concerns about safety and effectiveness, as the study’s findings suggest these medications may do more harm than good.

Antipsychotics and Worsening Behavior

The longitudinal study, which analyzed data from nursing homes across Canada between 2000 and 2022, found that about 70 percent of residents prescribed antipsychotics experienced worsening behavior. Residents given these medications were 27 percent more likely to experience worsening behaviors than those who didn’t receive the drugs.

In comparison, those not receiving these medications had lower rates of such declines.

The average age of the study’s residents was 83, and about 64 percent were women. Those receiving antipsychotics were more likely to suffer from depression, cognitive impairment, and frailty in addition to dementia, and had a higher risk of falls and delirium, according to the study.

Examples of worsened behavior from residents included changes in appetite or sleep, repetitive questioning, and inappropriate sexual behavior.

26 Percent of Antipsychotics Prescribed Off-Label

The study also revealed that more than a quarter (26 percent) of nursing home residents were prescribed antipsychotics off-label, meaning for purposes not approved by regulatory agencies such as Health Canada, which, like the U.S. Food and Drug Administration, regulates the use of these drugs.

Although antipsychotics are approved for conditions such as schizophrenia, they are often used for dementia-related behaviors. The study authors noted that off-label prescriptions were common, even though these medications are not very effective for changing behavior and come with serious risks.

“The reality is that these medications can make disability and cognitive impairment worse,” John Hirdes, a coauthor of the study and professor at the University of Waterloo in Waterloo, Canada, said in a press statement.

The trend of prescribing antipsychotics off-label is not restricted to Canada. A September 2023 analysis of more than 12,000 U.S. nursing homes by the Long Term Care Community Coalition, a nonprofit that advocates for older people and people with disabilities, found that more than one in five nursing home residents were prescribed antipsychotics even though they didn’t have a diagnosis of psychosis.

Travers, who coauthored a related study in April 2024, said that nursing homes in disadvantaged communities are more likely to overmedicate residents with antipsychotics, especially in understaffed homes. These medications are often prescribed in environments where resources are limited, and the staff may not have the time or training to explore alternative, nondrug interventions, Travers said.

Although the study did not explain the exact reason antipsychotics worsen behavioral symptoms, a 2019 study published in Frontiers in Pharmacology suggested that a combination of factors, including disruption of dopamine, a chemical in the brain that helps control movement, may be responsible. Antipsychotic medications interfere with dopamine, which can contribute to these adverse effects.

According to the study authors, common side effects of antipsychotics include tremors, muscle stiffness, and slowed movement, which can make it harder for people with dementia to function. These medications can also worsen cognitive decline, leading to increased agitation and other challenging behaviors.

Drug-Free Alternatives

The study authors recommended a shift toward person-centered care, which means understanding the root causes of a resident’s behavior and offering nondrug interventions.

“We need to seriously reconsider the use of antipsychotics for people who do not have conditions associated with psychosis,” Hirdes said in the press release. Instead of immediately turning to medication, nursing homes should prioritize strategies that address behavioral symptoms without drugs.

The researchers noted that effective nonpharmacologic strategies include behavioral, music, and art therapies, as well as appropriate physical exercise. These approaches have been shown to reduce symptoms such as agitation and aggression, improving residents’ well-being and quality of life.

Travers said there are many environmental and behavioral interventions that nursing homes can implement. However, she acknowledged that staffing shortages, lack of training, and sometimes resistance from families—“who may push for medication-based solutions,” especially when they are concerned about their loved one’s behavior—can complicate this shift.

Despite the challenges, Travers said it’s essential to recognize each resident’s unique needs. Behaviors such as agitation or wandering are often triggered by pain, hunger, or overstimulation. She recommended minor adjustments, such as tailoring mealtimes or routines to fit residents’ preferences, that can make a big difference.

Travers added that family members and caregivers can offer valuable insights into residents’ needs.

Signs of a Well-Run Nursing Home

In response to ongoing concerns about the overuse of antipsychotics, the Centers for Medicare & Medicaid Services (CMS) announced in January 2023 plans to audit nursing homes to encourage better prescribing practices and ensure residents receive the best care possible.

These audits focus on identifying when antipsychotic medications are prescribed appropriately, particularly for conditions such as schizophrenia. Nursing homes found to be inaccurately diagnosing schizophrenia or overprescribing these drugs may receive lower ratings on Nursing Home Care Compare, a source for those making placement decisions for family members.

“CMS has contacted hundreds of nursing homes ... and continues to conduct these audits,” a CMS spokesperson told The Epoch Times in an email. Many of the nursing homes audited have “attested to having Minimum Data Set (MDS) coding inaccuracies” in their records and are working to correct these issues.

For the remaining facilities, the CMS said the audits showed that there were often no complete mental health assessments, medical reviews, or detailed behavior records to support a diagnosis of schizophrenia or the use of antipsychotic medications, as required by medical standards.

To access the national and state average rates of antipsychotic medication use in specific nursing homes, follow these instructions:

1. Visit Medicare.gov/Care-Compare.
2. Search for a facility by name or location.
3. Click on a facility.
4. Select “View Quality Measures.”
5. Choose “Long-stay quality measures.”
6. View the “Percentage of long-stay residents who got an antipsychotic medication.”