Safer Psychotropic Use in Long-Term Care: A 2026 Stewardship Guide for Facility Leaders

Psychotropic medications can play an important role in long-term care. For some residents, an antipsychotic, antidepressant, anxiolytic, or hypnotic helps manage a diagnosed condition and supports safety or quality of life.

But continued use should never become automatic.

In 2026, safer psychotropic stewardship means regularly asking whether each medication still has a clear purpose, whether the benefits continue to outweigh the risks, and whether nonpharmacologic strategies or a lower dose could meet the resident’s needs.

For assisted living communities, skilled nursing facilities, and group homes, this approach supports better resident care and stronger survey readiness.

Important: This article is for operational education and does not replace clinical judgment, facility policy, state requirements, or advice from a qualified prescriber and consultant pharmacist.

Psychotropic stewardship starts with the resident: not the medication

A medication should be connected to a specific, documented clinical condition and clearly defined target symptoms. “Agitation,” “behavior,” or “sleep problems” alone may not provide enough information to evaluate whether a psychotropic remains appropriate.

A strong stewardship process asks:

• What diagnosis or clinical condition is being treated?
• What symptoms was the medication intended to improve?
• Has the medication produced a meaningful benefit?
• Are the symptoms still present?
• What adverse effects or safety risks have emerged?
• Have the resident’s goals of care changed?
• Could the same goal be achieved with a lower dose, a different treatment, or a nonpharmacologic intervention?

Federal requirements for Medicare- and Medicaid-certified nursing facilities are outlined in 42 CFR §483.45. The regulation addresses pharmacy services, monthly drug regimen reviews, unnecessary medications, psychotropic drugs, gradual dose reductions, behavioral interventions, and PRN psychotropic orders.

Assisted living and group home requirements may differ by state, but the same clinical principles remain useful.

Use nonpharmacologic approaches first when appropriate

Nonpharmacologic care is not a single intervention. It is a structured effort to understand what may be causing a behavior or symptom and to respond in a person-centered way.

Before initiating or escalating a psychotropic, the interdisciplinary team should consider potential contributors such as:

• Pain, constipation, urinary symptoms, hunger, thirst, or fatigue
• Delirium, infection, or an acute medical change
• Medication interactions or withdrawal
• Noise, crowding, poor lighting, or unfamiliar surroundings
• Loneliness, grief, fear, or unmet emotional needs
• Changes in routine, caregivers, room assignment, or activities
• Sleep disruption or lack of meaningful daytime engagement

Interventions may include pain management, toileting schedules, improved sleep routines, calming music, familiar objects, meaningful activities, mobility support, quiet spaces, redirection, validation, and consistent staff approaches.

The intervention should be specific. Instead of documenting “redirect as needed,” the care plan might state:

• Offer a quiet space and familiar music before evening care.
• Assign a consistent caregiver when possible.
• Provide a snack and toileting opportunity before activities.
• Use short, simple explanations before hands-on care.
• Record the resident’s response and identify patterns by time of day.

This information helps the team determine what works. It also shows surveyors that the facility is not relying on medication as a substitute for assessment, staffing communication, or person-centered care.

What the 2026 deprescribing consensus adds

The 2026 ASCP consensus statement published in JAMA Network Open provides a broad framework for reviewing psychotropic medications over time.

A task force of 45 international psychopharmacology experts reached consensus on 44 of 50 statements. The recommendations emphasize that deprescribing is part of good medication management: not a one-time event or a blanket instruction to stop treatment.

The consensus supports:

1. Periodic reassessment of every psychotropic medication. The task force recommends review at least annually, with more frequent review when the resident’s condition changes.
2. Adherence assessment before judging effectiveness. A medication should not be labeled ineffective if it has not been taken as prescribed or administered consistently.
3. Individualized risk-benefit decisions. Deprescribing should be considered when meaningful benefit is absent, treatment goals have been met, risks outweigh benefits, or the regimen is duplicative or no longer aligned with the diagnosis.
4. Shared decision-making. Residents, representatives, families, prescribers, nursing staff, and other members of the care team should understand the rationale and monitoring plan.
5. Close monitoring after a dose reduction or discontinuation.
6. One medication change at a time whenever feasible.

The consensus does not recommend stopping medications indiscriminately. A resident with ongoing psychosis, severe mood instability, or a history of serious relapse may require continued treatment. The key is to document why the medication remains necessary and how the resident is being monitored.

Gradual dose reduction should be planned, not improvised

A gradual dose reduction, or GDR, is a stepwise reduction intended to determine whether symptoms can be managed with less medication or without the medication.

For nursing facilities, CMS guidance generally expects GDR attempts twice during the first year of psychotropic therapy, in separate quarters, and at least annually thereafter unless clinically contraindicated. Facilities should verify current federal and state requirements and document the clinical basis for each decision.

A practical GDR plan should include:

• The medication, current dose, and target symptoms
• The reason for the reduction
• The reduction amount and timing
• Nonpharmacologic supports that will continue
• Who will monitor the resident
• What symptoms or adverse effects will be tracked
• When the interdisciplinary team will reassess
• What will happen if symptoms return or safety concerns emerge

Dose reductions should be individualized. A resident who has used a medication for a long time or who has previously experienced withdrawal or relapse may require a slower approach. The ASCP consensus favors gradual, carefully monitored tapering rather than abrupt discontinuation when deprescribing is clinically appropriate.

Monitoring should include more than a single behavior note. Consider tracking:

• Frequency and severity of target behaviors
• Mood, anxiety, psychosis, or sleep changes
• Falls, near-falls, sedation, or orthostatic symptoms
• Appetite, function, participation, and communication
• New or worsening abnormal movements
• Resident, family, and staff observations

If symptoms recur, the team should follow the pre-established contingency plan. That may involve pausing the taper, returning to the last effective dose, reassessing for a medical cause, or consulting the prescriber. A failed GDR is not necessarily a failure of stewardship. It can provide useful clinical information when the process is well planned and documented.

The consultant pharmacist’s role in monthly medication regimen reviews

Under 42 CFR §483.45, the drug regimen of each nursing facility resident must be reviewed at least monthly by a licensed pharmacist. The review must include the resident’s medical chart, not only the medication administration record.

For psychotropic stewardship, the consultant pharmacist can help the facility:

• Confirm that each psychotropic has a current indication
• Review whether target symptoms are clearly defined
• Identify possible GDR candidates
• Evaluate dose, duration, duplication, and drug interactions
• Assess monitoring for sedation, falls, metabolic effects, abnormal movements, and other risks
• Review PRN use and renewal documentation
• Determine whether behavioral interventions are present in the care plan
• Recommend medication changes or additional assessment
• Communicate irregularities to the prescriber, medical director, and director of nursing

Monthly medication regimen reviews are most useful when they connect directly to facility workflows. Pharmacist recommendations should be routed to the appropriate clinical leaders, discussed with the interdisciplinary team, and followed through to a documented response.

A recommendation that remains unanswered is not a completed stewardship process.

Build survey readiness into everyday documentation

Survey readiness is strongest when it is the result of consistent resident care: not a last-minute chart project.

For every resident receiving a psychotropic medication, facilities should be prepared to show:

• A documented diagnosis or specific clinical indication
• Defined target symptoms
• A current risk-benefit assessment
• Nonpharmacologic interventions that were attempted or considered
• Evidence of ongoing monitoring
• GDR attempts when appropriate
• A clear clinical rationale when GDR is contraindicated
• Monthly pharmacist review and follow-up
• Prescriber and interdisciplinary team responses
• Updated care-plan interventions

Facilities can use the CMS Critical Element Pathway for Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review as one resource when reviewing internal processes.

How the right pharmacy partner supports safer use

Psychotropic stewardship requires coordination among the facility, prescriber, nursing team, resident, family or representative, and consultant pharmacist. A responsive pharmacy partner can help make that coordination more consistent.

Look for a partner that supports:

• Reliable medication access and accurate dispensing
• Timely communication with facility staff and prescribers
• Clear medication regimen review follow-up
• GDR tracking and documentation support
• PRN monitoring
• Identification of duplicate therapy and medication-related risks
• Interdisciplinary collaboration
• Practical survey-readiness education

The goal is not simply to reduce medication use. The goal is to ensure that every psychotropic medication is necessary, effective, monitored, and aligned with the resident’s current needs.

A practical next step for facility leaders

Choose a small group of residents receiving antipsychotics or other psychotropics and complete a focused review:

1. Confirm the diagnosis and target symptoms.
2. Review recent benefits, adverse effects, and behavioral patterns.
3. Identify nonpharmacologic interventions currently in use.
4. Determine whether a GDR should be attempted or whether a clinical contraindication exists.
5. Create a monitoring and follow-up plan.
6. Review the case with the consultant pharmacist and interdisciplinary team.

Small, repeatable reviews can become a facility-wide culture of safer medication use.

One Pharmacy is ready to support long-term care leaders with dependable pharmacy services, medication coordination, and collaborative psychotropic stewardship. Contact One Pharmacy to discuss how your facility can strengthen resident care, GDR follow-through, monthly medication reviews, and survey readiness.

References and further reading

• ASCP Consensus Statement on Recommendations for the Deprescribing of Psychotropic Medications
• JAMA Network Open consensus statement indexed in PubMed
• 42 CFR §483.45: Pharmacy services
• CMS Critical Element Pathway: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review