Antipsychotic medications are used extensively in nursing facilities (NFs). When used for approved disease states - such as schizophrenia, Huntington's disease and Tourette's syndrome - their clinical benefits are widely accepted. In people with a predetermined or long-standing history of mental illness, the chronic use of an antipsychotic medication also may be deemed necessary to stabilize and improve functionality. Antipsychotic medications have been frequently used “off-label” in Alzheimer's disease and other dementia-related illnesses where the effectiveness of the treatment can show mixed results. The off-label use of antipsychotic medications for dementia-related illnesses is unsupported in the literature. However, in 2023, the FDA approved the use of the antipsychotic Rexulti® to treat agitation related to Alzheimer’s disease. The physician must consider the risks versus benefits before prescribing this medication, and non-pharmacological interventions should be the first line treatment in these situations.
In older adults with dementia, antipsychotics are only appropriate in a small number of instances. Yet, despite the Food and Drug Administration's black box warnings of increased mortality, the inappropriate use of antipsychotics as a chemical restraint in people living in Texas NFs who have dementia still persists. Significant risks - including higher blood sugar and cholesterol levels, weight gain, increased risk of falls, and decreased cognition - also are associated with the use of antipsychotics. These complications can lead to the worsening of other primary diagnoses. Rexulti® retains that black box warning, despite the new FDA approval for Alzheimer’s-related agitation.
Visit the Quality Monitoring Program’s Alzheimer’s Disease and Dementia Care web page for best practices in caring for people with Alzheimer’s disease or related disorders.
Music and Memory
Some Texas NFs have begun using individualized music playlists with patients who have Alzheimer's and other memory disorders to try to reduce the use of antipsychotic medication.
The HHS Music and Memory program began in 2015 with 32 NFs, later expanding to over 600 facilities across the state. The goal is to help people with Alzheimer’s disease or other forms of dementia reconnect with the world through specific, music-triggered memories. Family members and NF staff create personal playlists for use on digital music players, such as iPods.
Visit the Music and Memory webpage to learn how you can introduce this program to your facility.
Resources Created by HHS
- Improving Dementia Care: Strategies for Pharmacists in Long-Term Care Facilities (PDF) was developed as a resource for consultant pharmacists, as they work with prescribers to reduce the use of antipsychotic medications in nursing home residents.
- Improving Dementia Care: The Strategies for Prescribers (PDF) is a resource for physicians and other professionals who prescribe medications for nursing home residents. This brochure includes strategies prescribers can utilize to improve dementia care and reduce the use of antipsychotic medications.
- Improving Dementia Care: The Role of Prescribers (PDF) was developed as a resource for physicians, PA-Cs and Nurse Practitioners who work with nursing home residents. These professionals play a key role in the efforts to reduce the inappropriate use of antipsychotic medications in nursing homes.
- Center for Excellence in Aging Services and Long-Term Care is a collaboration between HHSC and The University of Texas at Austin School of Nursing, the Center is a web-based educational platform for the delivery of best practices. Phase I of the Center focuses on Antipsychotic Medications and alternative interventions for managing dementia-related behaviors.
- Limiting the Use of PRN Psychotropic Medications (PDF) provides prescribers and nursing home staff with helpful information regarding the use of psychotropic medications on a PRN basis.
- Evidence-based Best Practice for Antipsychotic Medications (PDF) provides evidence-based best practice guidelines for addressing management of antipsychotic medication use in the long-term care setting.
- Care Planning Dementia-Related Targeted Behaviors (PDF) is a sample care plan for managing the behavioral and psychological symptoms of dementia without using antipsychotic medications.
- Antipsychotic Medications and Dementia Care (PDF) provides information about antipsychotic medications prescribed for the off-label use in treating behaviors associated with dementia. Typical and atypical medications and their side effects are discussed.
- Reducing Unnecessary Antipsychotic Medications (PDF) provides information for routinely monitoring antipsychotic drug usage, dosages, gradual dose reductions, the outcomes of those reductions on behaviors, and suggested timeframes for conducting dose reductions.
- Alternatives to Antipsychotic Medications (PDF) discusses the stages of cognitive impairment, the components of a behavior management program, causes of behaviors (such as medical conditions and environmental triggers), suggestions for alternatives, and monitoring the results of using alternatives.
- Antipsychotic Medication Tracking Tool (PDF) helps nursing home staff reduce the inappropriate use of psychotropic medications. It can be helpful in documenting pre-psychotropic medication root-cause analysis, promoting a proper decision-making process by identifying targeted behaviors, adjusting dosages accordingly, and reducing the length of time in which unnecessary medications remain within an individual's drug regimen. The target audience is clinical staff.
- Antipsychotic Education Form (PDF) includes the potential benefits, risks and burdens of antipsychotic medications and presents alternatives to antipsychotic medications.
- Be DADS Wise with the Use of Antipsychotics (PDF) provides helpful information about antipsychotic medications and reducing the inappropriate use of these drugs in long-term care settings.
- Basic Guidelines for Quarterly Psychotropic Medication Evaluation (PDF) provides guidance for conducting quarterly psychotropic medication evaluations and evaluating the effectiveness of non-pharmacological behavior interventions.
- Basic Guidelines for Behavior and Side Effect Monitoring (PDF) describes techniques for conducting effective behavior and medication side effect monitoring.
- Antipsychotics: What's the Big Deal? (PDF) includes types of antipsychotic medications, side effects, prescribing considerations, risk factors with dementia, behaviors, and quality of life issues.
- View this HHS-produced video about Reducing Antipsychotics in Nursing Homes with Dr. Allen Power.
Resources from the Centers for Medicare & Medicaid Services
- National Partnership to Improve Dementia Care in Nursing Homes
- Hand in Hand: A Training Series for Nursing Homes Toolkit
- Survey & Certification Letter 12-44-NH: “Hand in Hand: A Training Series for Nursing Homes,” on Person-Centered Care of Persons with Dementia and Prevention of Abuse (PDF)
- Survey & Certification Letter 13-02-NH: Clarification of Guidance Related to Medication Errors and Pharmacy Services (PDF)
- Survey & Certification Letter 13-34-ALL: Release of Mandatory Surveyor Training Program on Care of Persons with Dementia and Unnecessary Antipsychotic Medication Use-Release of Third Video (PDF)
- Survey & Certification Letter 13-35-NH: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual and Appendix PP in the SOM for F309-Quality of Care and F329-Unnecessary Drugs (PDF)
- Survey & Certification Letter 14-19-NH: Interim Report on the CMS National Partnership to Improve Dementia Care in Nursing Homes: Q4 2011-Q1 2014 (PDF)
- Adverse Drug Event Trigger Tool (PDF)
Resources from Other Organizations
- American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults provides access to the 2019 revision to the Beers Criteria and related resources. Note: Access to these resources requires registration at the AGS website.
- Sane Use of Psychotropic Medications (PDF) addresses behaviors, altered mental status and treatment options.
- Diagnostic Checklist Clues to Identifying Causes of Common Behavior and Psychiatric Disturbances (PDF) can be used as a guide to match up findings related to the resident with known patterns and combinations of symptoms that may suggest a specific diagnosis.
- Dementia and Challenging Behavior Series is a series of six, web based modules, designed specifically for training nurse aides to work with residents with cognitive impairments. Registration is required before accessing this resource.