Assessing the Impact of the Long-Stay Antipsychotic Measure on Access to Patient-Centered Care

Millions of Americans are living with neurodegenerative diseases that affect their cognitive abilities, reshaping their lives and the lives of their loved ones. Alzheimer’s disease is the most common neurodegenerative disease; more than seven million Americans live with Alzheimer’s, and nearly 13 million additional diagnoses are expected by 2050. The vast majority of Americans diagnosed with Alzheimer’s disease are older adults, and many reside in skilled nursing facilities (SNFs) where they can receive specialized care. More than three million SNF residents are currently diagnosed with Alzheimer’s and related diseases (ADRD), representing approximately 48% of all SNF residents nationwide.

While cognitive decline is the main symptom of ADRD, neuropsychiatric symptoms (NPS)—including agitation, aggression, delusions, hallucinations, depression, anxiety, apathy, disinhibition, and sleep disturbances—are also quite common, with nearly half of all patients with neurocognitive impairment and up to 97% of those with Alzheimer’s disease experiencing one or more NPS. These symptoms are associated with accelerated disease progression and functional decline, as well as decreased quality of life, increased risk of hospitalization, earlier SNF placement, higher cost of care, greater caregiver burden, and earlier death. People living with ADRD tend to present with NPS in the later stages of their diseases, and these symptoms worsen with disease progression, raising important safety concerns. Multiple studies indicate that NPS are significantly associated with a higher risk of falls and injuries at SNFs and are among the leading causes of facility-initiated discharges. Managing NPS of ADRD is both a science and an art, as patients present with a variety of medical and psychosocial needs that require constant monitoring and treatment adaptation. Ensuring patient access to a range of treatment options, educating clinicians, SNF providers, families, and caregivers about these options, and maximizing flexibility are essential to delivering individualized, patient-centered care to a rapidly growing cohort of older adults with NPS and improving their quality of life.

In addition to an array of other pharmacological and nonpharmacological interventions, antipsychotic medications are one class of treatment for older adults with NPS of ADRD. In July 2012, responding to publicized concerns about overprescription of antipsychotics among long-stay SNF residents, the United States Centers for Medicare and Medicaid Services (CMS) launched the Long-Stay Antipsychotic Medication quality measure to monitor antipsychotic prescriptions to long-stay SNF residents. This quality measure is currently reported via the Nursing Home Care Compare Five-Star Quality Rating System and a critical factor in the calculation of Medicare-certified SNFs’ star ratings. The measure was intended to ensure patient safety and protect against the improper use of antipsychotics as chemical restraints. Since that time, clinical guidelines for the management of NPS among older adults with ADRD have evolved significantly. For example, the American Psychiatric Association issued a clinical guideline on antipsychotic use in 2016, and the United States Food and Drug Administration (FDA) approved two antipsychotic medications intended to specifically to treat NPS of ADRD in 2016 and 2023. CMS’ quality measure contains multiple flaws that penalize SNFs for prescribing antipsychotics unless the patient has one of a narrow set of diagnoses, thus restricting patients’ access to medications that are clinically indicated for the treatment of NPS. As the measure has its intended effect of lowering antipsychotic use across the long-stay SNF population across the board, its relentless pressure forces many SNFs to halt antipsychotic use in cases where these medications are clinically appropriate or even essential.

Clinicians, quality measure experts, provider and health professional societies and associations, government agencies, researchers, and patient advocacy groups, including the Alliance for Aging Research, American Society of Consultant Pharmacists, and members of Project PAUSE (Psychoactive Appropriate Use for Safety and Effectiveness), have repeatedly warned CMS about the measure’s potential for unintended consequences in quality of care and patient outcomes. However, CMS has only revised the measure once, more than a decade after its launch, to supplement what was its sole data source with three additional sources. This revision, announced in June 2025, seeks to address some longstanding concerns with the measure’s accuracy and ensure that all long-stay SNF residents’ use of antipsychotics is captured accurately and their indications are accounted for. While CMS’ action represents a step toward better measure design, it leaves other significant and longstanding problems with the measure unaddressed, specifically:

• The measure fails to distinguish between clinically appropriate and inappropriate use of antipsychotic medications.
• The measure may have increased inappropriate prescriptions of other psychotropics (e.g., anticonvulsants, antidepressants, anxiolytics) and opioids as substitutes for antipsychotics.
• The measure does not reflect current clinical guidelines.
• The measure incorporates inaccurate diagnosis coding and insufficient exclusion criteria.
• The measure’s use in the Nursing Home Care Compare Five-Star Quality Rating System lacks critical context for patients, families, and caregivers.

CMS initially committed to incorporating the updated measure in the Nursing Home Care Compare Five-Star Quality Rating System in October 2025; however, its incorporation has since been delayed until January 2026. CMS has both the required authority and a broad base of support in the current federal environment to streamline Medicare regulations and remove unnecessary administrative burdens on SNF providers by enacting one or more of the following changes to the measure, any of which could be undertaken without compromising patient safety or the integrity of the Medicare program:

• Further Revise Quality Measure
  • Identify Evidence-Based Benchmark
  • Expand Exclusion Criteria
  • Conduct Additional Stakeholder Engagement to Support Further Respecification
  • Develop Supplemental Quality Measure
• Remove Quality Measure from Nursing Home Care Compare Five-Star Quality Rating System
  • Reclassify Current Measure as Information-Only and Provide Necessary Context for Results
  • Suspend Public Reporting of Current Measure and Charge United States Government Accountability Office with Studying Clinically Appropriate vs. Inappropriate Antipsychotic Prescribing
  • Suspend Public Reporting of Current Measure and Respecify to Define as Antipsychotic Use without Indication or Documentation of Appropriateness Criteria
• Retire Quality Measure

With support from the Alliance for Aging Research, this paper from Manatt Health further describes the importance of maximizing treatment options for SNF residents with NPS of ADRD and the options available to CMS to strengthen quality measurement in this area while preserving access to patient-centered care.

Click to to read the executive summary and  to read the full paper.

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NPS of Alzheimer’s and related diseases are also referred to as behavioral and psychological symptoms of dementia in some clinical contexts.

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Not all older adults with Alzheimer’s and related diseases reside in SNFs. Many in assisted living facilities, continuing care retirement communities, subsidized senior housing, group living arrangements, or at home and receive long-term care services (e.g., personal care assistance, home-delivered meals, adult day health care).

Hanna-Maria Roitto, Hannareeta Öhman, Karoliina Salminen, et al., “Neuropsychiatric Symptoms as Predictors of Falls in Long-Term Care Residents With Cognitive Impairment,” Journal of the American Medical Directors Association 21, no. 9 (1243-1248), ; “Nursing Home Residents with Endangering Behaviors and Mental Health Disorders May Be Vulnerable to Facility-Initiated Discharges,” U.S. Department of Health and Human Services Office of Inspector General, issued March 2024, ; Elizabeth E. Hathaway, Jennifer L. Carnahan, Kathleen T. Unroe, et al., “Nursing Home Transfers for Behavioral Concerns: Findings from the OPTIMISTIC demonstration project,” Journal of the American Geriatrics Society 69, no. 2 (2021): 415-243, ; “Resident and Facility Factors Associated with High Risk of Discharge from Nursing Facilities, 2012-2017: Final Report,” U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation, issued September 2022, .

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