Meds are often the go-to for dementia patients. Is there a better way?

After Bobby Tweed moved into a Tennessee nursing home, the once-spirited 78-year-old with dementia grew listless and withdrawn. Tweed, a gentle man who his daughter, Robin Tweed Keller, says “never hit anybody in his whole life,” was suddenly labeled “agitated” after a scuffle with another resident. In reality, Tweed was suffering from a common, treatable urinary tract infection, a physical condition well known to trigger temporary delirium and behavioral changes in dementia patients. Doctors treated him for the infection, but facility staff still turned to powerful psychotropic drugs that, according to a wrongful death lawsuit , were administered without his family’s knowledge or consent. The medications achieved what they were meant to do: They stopped behaviors caregivers found difficult. “They just kept him drugged up so they didn’t have to deal with him,” says his daughter, Keller. Tweed was left in a stupor so deep that family members couldn’t wake him up, no matter the time of day they visited. As her father retreated behind a chemical haze, Keller was left wondering whether what staff called “agitation” was really a language that no one had tried hard enough to understand. That possibility is at the center of an ongoing struggle in dementia care, outlined below by Knowable Magazine . While memory loss is the hallmark of dementia, the disease is also marked by troubling changes in behavior — such as aggression, shouting, irritability and depression. These symptoms are frequently treated with antipsychotics, despite longstanding warnings about serious risks of their use in older adults with dementia. A pair of 2026 federal watchdog reports indicate that the practice remains deeply entrenched in U.S. nursing homes. The Department of Health and Human Services Office of Inspector General found that facilities still use the medications as “chemical restraints,” often without first attempting required non-pharmacological interventions. Investigators also detailed how some facilities hide their true prescribing rates by inappropriately diagnosing residents with schizophrenia , a condition excluded from federal quality measures tracking antipsychotic use. “It’s showing that the problems continue to exist in full force in nursing homes, and we still have not solved this problem, and we still need to do more,” says Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. The issue extends beyond care homes to older adults receiving care in a range of settings, including those living in residential facilities and those remaining in their own homes. In all, national prescribing data shows that antipsychotic use among adults 65 and older increased by nearly 52% between 2015 and 2024, with long-term use (defined as more than four months) rising by almost 65%. The analysis included more than 8 million older Americans who received at least one antipsychotic prescription, reflecting the broad use of drugs whose benefits and risks remain hotly debated. In response, many clinicians and advocates are pushing for a different approach. Rather than treating these dementia-related actions as symptoms to be suppressed, they are instead describing them as expressions of unmet needs. “Behaviors can have meaning to people with dementia,” says Jennifer Watt, a geriatrician at the University of Toronto and a coauthor of a 2026 article on the subject in the Annual Review of Clinical Psychology. As language deteriorates, people may express themselves through actions instead of words. A person wandering the kitchen may be hungry or thirsty but unable to articulate it. Someone resisting a bath may be reacting to cold water or pain from arthritis. “It’s actually just people trying to communicate a need in the only way that they are able to at that point in time,” Watt says. Poorly defined symptoms Nearly every person diagnosed with dementia — an estimated 97 percent — will eventually experience changes in mood, perception or behavior. “There are complexities of the neurodegenerative changes in the brain that fundamentally alter how the brain works,” says Watt. The precise mechanisms behind these manifestations remain poorly understood. Some develop anxiety or depression. Others grow emotionally flat and withdrawn. Hallucinations and delusions may distort reality. Many develop what clinicians call “agitation,” a broad and imperfect term that can include pacing, restlessness, repetitive questions and sudden flashes of anger or even violence. Clinicians often group these experiences under the umbrella of “behavioral and psychological symptoms of dementia,” or BPSD. For decades, nursing homes, hospitals and other residential care settings have often responded with antipsychotic medications . Originally developed in the 1950s for schizophrenia, antipsychotics became widely used in dementia care to manage BPSD behaviors such as hallucinations, delusions, agitation and aggression — symptoms that can also occur in schizophrenia. By the 1970s, federal investigators were already warning that nursing home residents were being chemically restrained . Reforms beginning in the 1980s helped to curb the use of older, “typical” antipsychotics, but a newer generation of “atypical” drugs, considered safer, soon took their place. Then in the early 2000s, studies linked these newer antipsychotics in older adults with dementia to sharply increased risks of death, stroke, heart failure and accelerated cognitive decline. Mounting evidence of these and other serious harms , including a heightened risk of bone fractures related to falls, prompted the U.S. Food and Drug Administration to issue its strongest “black box” warning . Federal regulators introduced new oversight measures, including adding antipsychotic use to Medicare’s public Five-Star Quality Rating System , which tied a facility’s score to its prescribing rates. Use declined over the years, only to rise again during the COVID-19 pandemic, when staffing reached critical lows and family visits were restricted. Today, antipsychotic use remains substantial: Under a newly revised federal measure designed to capture prescribing more accurately, about 17% of long-stay nursing home residents receive an antipsychotic. Despite their widespread use, antipsychotics are only marginally effective in treating the behavioral symptoms of dementia. Results from randomized controlled trials are frequently characterized as weak ; larger analyses suggest benefits that are barely perceptible compared with placebos. While these drugs are powerful sedatives that can make a person docile, experts say they do little to solve the actual distress the individual is experiencing. “Instead of getting to the root problem and addressing the problem, we’re quieting them down,” says Smetanka. “And then that’s what leads to significant problems with their health and well-being.” On top of the medications’ direct risks, a resident who is sleepy or less responsive may move less and be less able to signal pain or a new illness. Best practice vs. in practice Medical guidelines generally recommend trying non-drug approaches first for behavioral symptoms of dementia. In practice though, medications are often the default. Growing efforts to close that gap are rooted in the idea that behaviors in dementia can have “meaning” — that they may signal unmet needs rather than simply be symptoms to suppress. Non-drug approaches range from personalized music playlists and walking programs to reminiscence therapy using old photographs and household objects. More specialized methods, such as one called Snoezelen therapy, use controlled light, sound, texture and scent to calm people experiencing sensory overload or deprivation. Unlike antipsychotic medications, non-pharmacological interventions are generally considered low risk, though the evidence supporting their effectiveness remains mix