The Commission’s first Australian Atlas of Healthcare Variation found high and varied rates of antipsychotic medicines dispensed for people aged 65 and over. The repeat analysis in the 2018 Atlas indicated that there has been little change in the overall amount of use. The current use of antipsychotic medicines outside current guideline recommendations as a form of restrictive practice to manage behavioural and psychological symptoms of dementia (BPSD) in aged care homes is a matter of grave concern. The Commission proposed a series of regulatory responses.