By Dr. Allen Power, Schlegel Chair in Aging and Dementia Innovation
Recent calls to relax antipsychotic reduction targets in senior living should concern all of us. Not because the targets are perfect—but because lowering expectations risks normalizing a practice that has long compromised the well-being, and even the lives, of people living with dementia.
We are being told that the current standards for reducing these medications may be “hurting providers’ quality metrics.” But we should be asking a more fundamental question: when did protecting metrics become more important than protecting people?
Antipsychotic medications were never designed to treat dementia. Yet they are widely used to manage distress—what is often labelled as agitation, aggression, or “behavioural symptoms.” These labels obscure a deeper truth: people living with dementia are not exhibiting symptoms of disease. They are expressing unmet needs stemming from a system that does not adequately support their well-being.
A person who is calling out may be afraid. Someone who resists care may feel unsafe or unheard. A resident who “wanders” may be searching for connection, purpose, or familiarity. These are not problems to suppress—they are signals to understand.
And yet, instead of addressing these root causes, we often reach for medication.
The risks are well documented: increased rates of stroke, falls, pneumonia, cognitive decline and death. But beyond the clinical risks is a more profound harm—the loss of voice, agency, and personhood that can come with sedation.
Advocacy groups suggesting we ease up on reduction efforts are responding to pressures in the system. Staffing shortages, regulatory burdens, and increasing care complexity are real challenges. But lowering the bar is not a solution—it is a retreat.
For more than two decades, I have argued that we need to “change our minds about those whose minds have changed.” That begins with reframing what we see.
Dementia is not simply a collection of “neuropsychiatric symptoms.” It is a shift in how a person experiences the world. Distress arises when that world no longer meets fundamental human needs, needs well-illustrated by the framework of The Eden Alternative Domains of Well-Being®—identity, connectedness, security, autonomy, meaning, growth, and joy.
When these needs are supported, distress nearly always diminishes—without medication.
We have seen this work in practice. Organizations that adopt a well-being-focused, person-centred approach routinely achieve antipsychotic use rates far below current targets. In Arkansas, for example, an application of my approach led by my colleague Dr. Angela Norman has reduced usage to an average of 4.6 per cent across more than 100 long-term care homes—without compromising safety.
This is not an unrealistic ideal. It is a proven alternative.
But it requires a shift in priorities. Instead of designing systems around efficiency and compliance, we must design them around people. That means investing in staff education, giving care partners the time to build relationships, making important operational shifts and creating environments that reduce distress rather than provoke it.
It also means recognizing that this issue extends beyond nursing homes. Many individuals are prescribed antipsychotics long before they enter long-term care—in hospitals and community settings—carrying that trajectory with them. Well-being is inadequately recognized and supported wherever people live.
Overprescribing is not a failure of individual providers. It is a reflection of a system that rewards quick fixes over meaningful care and sees pathology rather than expressions of humanity.
If we are serious about improving dementia care, we cannot lower expectations. We must raise them.
The goal should not be to better “manage behaviours.” It should be to better understand people.