A national coalition is urging federal regulators to rewrite a key nursing home quality metric tied to antipsychotic use, arguing the measure is discouraging appropriate treatment for residents living with Alzheimer’s disease and related dementias.
Project PAUSE (Psychoactive Appropriate Use for Safety and Effectiveness) on Wednesday released a white paper calling for changes to the Centers for Medicare & Medicaid Services’ Long-Stay Antipsychotic Medication Quality Measure. The group says the metric, which feeds into public reporting and the Five-Star Quality Rating System, has created a chilling effect on prescribing and is harming residents who need carefully managed medication for severe behavioral symptoms.
CMS has not issued a formal response. In past statements, the agency has said it aims to reduce unnecessary antipsychotic use while preserving access to appropriate care.
What the coalition wants changed
The white paper outlines several reforms. Chief among them: exempting residents with Alzheimer’s and related dementias from the penalty structure, improving diagnostic coding requirements to curb workarounds, and incorporating person-centered assessments that account for clinical nuance. The coalition also wants the measure removed from public star ratings to avoid what it describes as reputational penalties that may deter legitimate prescribing.
“The current measure, while well-intentioned, has created an environment of fear that restricts access to safe and effective treatments for millions of nursing home residents living with Alzheimer’s and related dementias,” said Robin M. Weinick, executive director of Project PAUSE, in a statement announcing the report. “We urge CMS to reform this metric to better reflect clinical realities and prioritize patient-centered care.”
A measure with unintended consequences
CMS introduced the antipsychotic metric more than a decade ago to curb overuse of the drugs, which carry serious risks for older adults with dementia. The Food and Drug Administration has long warned of increased mortality among this population, and regulators require facilities to attempt non-drug interventions first.
Project PAUSE argues the pendulum has swung too far. The coalition says appropriate prescribing has fallen 20% to 30% since the metric took hold, a trend it links to facilities’ fear of star-rating downgrades or survey citations. Roughly half of long-stay nursing home residents have dementia, according to Alzheimer’s advocates, and some experience dangerous agitation or psychosis that may require short-term, closely monitored antipsychotic use.
“Our analysis shows that the measure’s one-size-fits-all approach ignores the evidence-based role of antipsychotics in managing severe symptoms,” said co-author Krista L. Lanctôt, PhD. “This isn’t quality improvement — it’s unintended harm.” Co-author Mark E. Kunik, MD, added that facilities often face a “compliance trap: prescribe and risk citations, or withhold and watch residents suffer.”
Balancing safety with access
The debate reflects a longstanding tension in long-term care: how to protect residents from misuse without blocking treatment when symptoms escalate. Industry reports and past federal reviews have flagged problems on both sides — from historical overprescribing to questionable diagnostic coding used by some facilities to avoid penalties. A 2021 federal watchdog report, for example, raised concerns about a spike in schizophrenia diagnoses that did not always match clinical records.
Project PAUSE’s members include advocacy groups, clinicians and provider organizations. The coalition also points to recent oversight changes as reason to revisit the metric’s design, noting updated surveyor guidance on psychotropic drugs took effect in 2025.
Not everyone agrees with the coalition’s approach. Some consumer advocates worry that loosening the measure or detaching it from public ratings could open the door to overuse. Supporters counter that targeted revisions — like refining diagnostic standards and requiring documentation of non-drug strategies — would maintain safeguards while allowing necessary care.
What happens next
The coalition is urging CMS to convene a technical expert panel and begin rulemaking to modify or replace the current measure. It plans outreach through the end of the year, including a December webinar, to build consensus around changes.
“This measure succeeded in curbing abuse, but it’s now limiting access,” said health policy researcher David Grabowski in public comments on the report. “Decoupling from star ratings and tightening clinical criteria could restore balance without turning back the clock.”
For now, providers remain caught between regulatory pressure to limit antipsychotics and the clinical realities of serving a growing dementia population. The question before CMS is whether the metric can be recalibrated to reflect both.
