The Risks of Inappropriate Antipsychotic Use in Nursing Homes

Antipsychotic medications are sometimes used in nursing homes to manage behavioral symptoms in residents with dementia or other cognitive impairments. While these drugs may seem like a solution for agitation, aggression, or hallucinations, they come with serious risks and potential regulatory penalties if used inappropriately.

According to the Centers for Medicare & Medicaid Services (CMS), overuse of antipsychotics in nursing homes remains a critical issue. The federal government and advocacy organizations like Qsource are actively working to reduce unnecessary antipsychotic prescriptions and promote safer, more person-centered approaches.

The Dangers of Inappropriate Antipsychotic Use

Antipsychotic medications are not approved by the FDA to treat dementia-related behaviors, yet they are frequently prescribed off-label for this purpose. Unfortunately, this can lead to devastating health consequences for residents.

Increased Mortality Risk

The FDA has issued a black box warning for all antipsychotics, cautioning that elderly patients with dementia-related psychosis are at an increased risk of death when taking these medications. The leading causes of death include:

• Heart failure
• Sudden cardiac arrest
• Stroke
• Severe infections, including pneumonia

A 2015 study published in JAMA Psychiatry found that the mortality risk is significantly higher in the first 180 days of antipsychotic use, making it especially dangerous when prescribed as a quick fix.

Sedation and Cognitive Decline

Antipsychotics do not cure dementia—they primarily work by suppressing brain activity to reduce agitation and aggression. This sedation often leads to:

• Severe drowsiness and lethargy
• Difficulty engaging in social activities
• Worsening confusion and memory loss

Instead of improving behaviors, these medications often accelerate cognitive decline, making it harder for residents to interact with others and engage in meaningful activities.

Increased Fall and Fracture Risk

Many antipsychotics cause dizziness, muscle weakness, and impaired coordination, which drastically increases the risk of falls. In nursing home residents, falls can lead to severe injuries, including:

• Hip fractures
• Head trauma
• Permanent mobility issues

A 2020 study in the Journal of the American Geriatrics Society found that nursing home residents on antipsychotics were 1.6 times more likely to experience falls and fractures.

Stroke and Cardiovascular Events

Antipsychotic medications affect dopamine and serotonin receptors, which play a role in blood pressure regulation and cardiovascular health. This can lead to:

• Increased risk of stroke (especially in the first few weeks of use)
• Severe changes in blood pressure
• Heart arrhythmias and palpitations

For residents with pre-existing heart conditions, antipsychotics can be life-threatening.

Metabolic Side Effects: Weight Gain, Diabetes, and High Cholesterol

Long-term antipsychotic use is linked to significant metabolic issues, including:

• Severe weight gain
• Insulin resistance and Type 2 diabetes
• High cholesterol and increased heart disease risk

Many residents on atypical antipsychotics (such as Olanzapine and Risperidone) experience rapid weight gain, making existing health conditions even harder to manage.

Pneumonia and Aspiration Risks

Sedation from antipsychotics can impair swallowing ability, leading to aspiration pneumonia—one of the most common causes of hospitalization and death in elderly residents. This is especially concerning for:

• Residents with dysphagia (swallowing difficulties)
• Those on feeding tubes or requiring assistance with eating

Studies show that elderly patients taking antipsychotics are twice as likely to develop aspiration pneumonia than those who are not.

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Regulatory and Legal Consequences of Antipsychotic Overuse

The CMS National Partnership to Improve Dementia Care has set clear goals to reduce unnecessary antipsychotic use in nursing homes. Facilities that fail to comply face significant penalties.

CMS Quality Measures and Five-Star Ratings

• CMS tracks and publicly reports the percentage of long-stay residents receiving antipsychotics.
• Higher usage rates negatively impact a facility’s Five-Star Quality Rating, which can affect reimbursement rates and reputation.
  
  

F-Tag 758: Free from Unnecessary Psychotropic Medications

• Ensure your MD appropriately documents why an antipsychotic is being used, especially if it is used in combination with another medication to manage dementia and has been shown for that resident to be appropriate. This is essential to ensure the facility mediates deficiency risk, and ensures the resident gets personalized care.
• Facilities that fail to show proper documentation of behavioral interventions before prescribing antipsychotics risk deficiencies and citations.

Increased Risk of Lawsuits

Families have successfully sued nursing homes for wrongful death and neglect linked to inappropriate antipsychotic prescribing. Without proper documentation and informed consent, facilities can face severe legal and financial consequences.

Partner with Experts Like Qsource

Organizations like Qsource provide critical support to help nursing homes:

• Implement strategies to reduce antipsychotic use
• Train staff on behavioral management techniques
• Improve CMS compliance and Five-Star Ratings

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Inappropriate antipsychotic use puts residents at risk and exposes nursing homes to regulatory penalties. While these medications may be necessary in some cases, they should never be used as a first-line treatment for dementia-related behaviors.

By prioritizing non-drug interventions, obtaining informed consent, and following CMS guidelines, facilities can improve resident safety, well-being, and regulatory compliance.