Improving appropriateness of antipsychotic use in long-term care
When prescribed appropriately – to treat psychosis related to a psychiatric condition like schizophrenia – antipsychotic medications can improve a patient’s quality of life. However, too often it appears antipsychotics are being prescribed to residents of Long-Term Care Homes (LTCH) to control behavioral symptoms of dementia (such as verbal or physical aggression) without a concurrent psychiatric diagnosis.
This is concerning, because these medications have serious side effects such as loss of energy and drowsiness, which can impact quality of life. They have also been associated with an increased risk of stroke, heart disease, kidney failure and falls, which result in an increased risk of premature death.
The problem of inappropriate and over prescribing of antipsychotics has recently been put back in the spotlight by a Health Quality Ontario report that demonstrates a wide variance in prescription rates across LTCHs in Ontario.
Ontario is not the only jurisdiction trying to improve the appropriateness of antipsychotic use in LTCHs. Over the past two years, Alberta has embarked on an ambitious attempt to reduce inappropriate use of antipsychotics across the entire province, and the approach so far seems to be working. What are the key features of this program? And what can Ontario and others learn from this ambitious initiative?
Current state of antipsychotic use in Ontario
Health Quality Ontario’s report notes that there has been a modest decrease in antipsychotic use in LTC facilities from 32% to 29% of residents since 2010. But prescribing rates vary across individual LTC facilities with the lowest reported rate of antipsychotic use being 0% and the highest 67%. These numbers include residents diagnosed with psychosis, as well has residents that have dementia without psychosis or no diagnosis of either dementia or psychosis.
The modest decrease over the last few years may be due in part to Ministry of Health and Long-Term Care funded initiatives such as Putting the PIECES together and Behavioural Support Ontario, which aim to provide LTCH staff with better training to serve patients with dementia.
Candace Chartier, CEO of the Ontario Long Term Association, believes part of the decline in antipsychotic use is due to a culture change within LTCHs. “We’ve gone a long way from admitting residents and filling their meds, and not really identifying if those are the right meds for them. It’s a very proactive case now. You’ve got medication reconciliation that happens now,” she says.
However, the high level of variation in antipsychotic use between Ontario’s LTCHs suggests not all homes are equally proactive on this front.
What’s driving inappropriate use of antipsychotics?
Aggression is not unique to people with dementia, and most people with dementia will never behave aggressively. However, nearly one third of people with dementia (especially in the advanced stages), will at times behave aggressively. Frequently, aggressive behaviors are triggered by social and environmental factors such as social isolation, changes in routine, or feeling ignored, as well as psychological factors such as depression or stress due to not being able to complete tasks. Often, these factors are amplified when a person is admitted to a hospital or long term care facility, where antipsychotics are used to reduce aggression, even when social, environmental or psychological interventions would be more appropriate.
According to Kiran Rabheru, a geriatric psychiatrist at The Ottawa Hospital, the problem of inappropriate antipsychotic use is a systemic symptom of wider issues in the complex, continuing care sector. Calling for an increase in alignment between patients’ goals of care and service delivery, he notes that long-term care homes, as currently designed, do not provide the environmental and psychosocial support that residents require. Citing a lack of training for frontline staff, he suggests that the biggest impact we can make is to provide frontline staff with the training and confidence they need to address aggressive behaviours.
Miranda Ferrier, co-chair and president of the Ontario Personal Support Worker Association, supports this call for increased training, noting that personal support workers lack consistent training on managing aggressive behaviours, are often not included in multidisciplinary health care teams and are understaffed.
Another root of the problem is lack of knowledge about the alternatives. A 2008 study, by Paula Rochon, vice president of research at Women’s College Hospital and her colleagues found that regulatory warnings from Health Canada and pharmaceutical companies about the adverse effects of antipsychotics on patients with dementia had a limited impact on prescription practices. “When you have a warning and it tells you not to do something, it doesn’t necessarily tell you what to do. And in the case of being told not to prescribe one drug, we don’t have another drug to go to that’s safe and works, that’s a clear option,” she explains.
Finally, a contributor to inappropriate use of antipsychotics in LTCH can be a breakdown in transitions of care between hospitals and LTCH. In some cases, a patient with dementia may be prescribed an antipsychotic during an acute illness if staff members are not able to manage the patient’s behavioral symptoms. However, upon discharge from the hospital, the antipsychotic may not be discontinued, so a patient may remain on the medication indefinitely.
Alberta’s systematic approach to improving the appropriate use of antipsychotics
One approach that has shown considerable preliminary success is the Appropriate Use of Antipsychotic (AUA) initiative in Alberta.
Faced with wide regional variation in antipsychotic use across the province, Alberta Health Services (AHS) Seniors Health Strategic Clinical Network piloted the AUA project in 11 long-term care sites. The aim of the project was to reduce these medications with the use of person-centered strategies.
The AUA provided resources to assist facilities in developing individualized care plans through family consultations and team problem solving. Sites were expected to implement a 12-step sequential action plan and were supported with a toolkit of resources.
A cornerstone of this approach is the implementation of regular medication reviews, including at admission and following a prescription of an antipsychotic. Verdeen Bueckert, AUA practice lead, found that while many sites were already required to review antipsychotic use regularly, they lacked a process that allowed them to do it effectively. The AUA provided evidence-based resources to simplify and standardize this process. (Bueckert notes that many of these resources were adapted from work originally done in British Columbia and Winnipeg.) Facilities participating in the AUA initiative now review a patient’s antipsychotic prescription every month, to determine whether the patient should continue on the medication.
This approach also stresses non-pharmacological management as first-line treatment for behavioral symptoms of dementia. These social and environmental interventions include providing more structure to a patient’s day, scheduling events to adjust to a patient’s needs, and shifting an agitated patient into an activity he or she enjoys such as going for a walk or listening to music. It also recommends verbal and non-verbal communication techniques such as speaking at eye level, approaching from the front and communicating in a clear, empathetic, adult tone of voice. All of these techniques are evidence-based, and aim at adjusting the physical, environmental and psychosocial stressors that may lead to aggression.
The preliminary results of this initiative have been quite encouraging. Like Ontario, Alberta has experienced a modest decline in the percentage of LTC residents on antipsychotics, from and average 26% in 2012 to 22% in 2014. However, the 11 AUA early adopter sites were able to reduce their use of antipsychotics by half within 9 months, without changing staffing ratios.
“In the majority of cases, these drugs can be stopped without detriment and with improvement in function,cognition and social engagement of the individuals,” explains Duncan Robertson, senior medical director of the AHS Seniors Health Strategic Clinical Network. “So, not only are we doing something that is avoiding harm, we’re actually benefiting, at least the majority of individuals.”
Additional benefits have included an increase in staff workplace satisfaction, improvement in the quality of life for residents and greater attention to the underlying causes of behavior including pain, side effects from other medications and actual psychotic illnesses. It became “less of a project aiming to reduce inappropriate antipsychotic use and more a project to support LTCHs in their dementia care,” notes Dennis Cleaver, executive director of the Seniors Health Strategic Clinical Network.
The effort has not been without its challenges. Bueckert explains that one of the primary obstacles that the initiative faced was tackling workplace cultures in which the use of antipsychotics is believed to be a safe, efficient and effective intervention, and alternatives are seen as staff-intensive and inadequate. According to Bueckert, disrupting these assumptions required “cautious exploration” on the part of frontline workers, as well as buy-in from long term care leaders, physicians and family members. “They had to be convinced by their own experience that it was safe to stop using antipsychotics,” she says.
In search of system-wide improvement
Regular medication reviews, person-centered care, empowered front line staff and knowledge translation have all contributed to the culture change and reduced Alberta’s antipsychotic use in LTC.
Another strategy that has been utilized in other jurisdictions including the United States has been requiring public reporting on antipsychotic use in LTCH.
Starting in June 2015, the Canadian Institute for Health Information (CIHI) will expand its web-based tool Your Health System to provide individual and regional LTCH indicators including the inappropriate use of antipsychotics and restraint use in LTCH. This nation-wide public reporting of individual LTCH indicators will be the first of its kind in Canada and it may provide increased incentive to reduce this problem.
Inappropriate prescribing of antipsychotics in long term care homes is not a new problem. While it is heartening to see there has been a decline in the use of these medications over the past few years, this decline has been modest, and the variation in practices continues to be a concern. With 95% of Alberta’s LTCHs now participating in the AUA program, many policy makers pursuing true system-wide improvement will no doubt be watching closely to see whether Alberta can expand and sustain their preliminary successes at the provincial level.