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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.

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13 comments

  1. Jim McCarthy

    It is interesting that antipsychotics are also used for what is felt to be aggressive verbal behaviour in the absence of a diagnosis of dementia, used simply to not have to do one’s job in helping a patient. This has been our recent experience and not in an LTHC but in a primary care hospital with a patient admitted and being treated for sepsis and no history of dementia. It was simply a convenience for the staff and the patient record indicated it was to be used “as needed”, which became every night for a week! It was also combined with the use of Lorazepam.
    I would like to think that there should be a protocol in place to ensure that it’s use is justified – which would include the responsible physician, pharmacy, and a patient representative (e.g. – POA). The patient in this case began to show signs of many of the symptoms of its use, signs which were simply ignored.

  2. Shehla Shukoor

    Excellent-well written article! Residents in long term care facilities are being overly medicated with anti-psychosis which is really a ‘Band-Aid approach to the problem, however addressing it as a systemic health crisis and being patient centered is truly the best way to proceed. I really liked the comparison between these two provinces and hopefully with Alberta’s success, this will be implemented at a national level. In the past I have worked with caregivers of dementia, I can see how aggression can be a trait that many are not comfortable with, in fact are feared about what may happen however this is problematic as we are not really addressing the issue when we resort to meds as being the cure. Every behavior has a purpose, and when the person is becoming agitated and irritated, we should not jump to the ‘meds’ but rather focus on de-escalating the level of the stress the patient is in. This article can be compared to how our education system overmedicates special needs children who cannot sit in class we assume medication does the trick but it actually brings more problems in the future. Overall, great article and it brought about a lot of awareness of the reality of Long Term Care facilities.

  3. Trish Rawsthorne

    It is interesting that the spin on this decades old problem of drugging residents into submission with the use of inappropriate harmful drugs (chemical restraints) jumps from the “inappropriate use” to the “appropriate use” all the while those in the expert fields are advocating the use of non-pharmaceutical interventions.
    Very simply put if you take the average elderly person out of their familiar setting and lock them away in a setting that is so foreign to them and is built for the service providers not the resident, you can expect a few of them to object. If you don’t offer the residents any stimulation, any comfort or dignity and respect, they will object and want out of their.
    No one wants to ever be put into a nursing home.
    My suggestion is to make it mandatory for government officials in charge of long term care programs, MLAs, a pharmacist or two, administrators and social workers of these facilities and a few staff to have to spend a week or more in their facilities and see how long they would last without complaining verbally to loneliness, boredom and helplessness these facilities for the most part force upon our elders.
    Stop building warehouses that don’t resemble any living accommodation these people have lived in before. Stop treating aging as an illness and start providing the comfort and caring that these people deserve in a home-like residence.
    It is never appropriate to drug people into submission or to silence them. Appropriate use of a specific drug for a specific diagnosis requires consent of the person or their legal representative. I truly doubt that one third of all residents in Long Term Care facilities have the appropriate diagnosis of schizophrenia or psychosis. Along with the consent to treatment, the full risks must be explained to the person/representative. The consent must be in writing. Not every person with dementia has lost their ability to say yes or no, but in Long Term Care facilities their opinions seem not to be considered or matter, as that would “inconvenience those in charge of them”.
    If the public does not speak out about this treatment of our elderly, we will be assured of the same treatment over the next 40-50 years and all I can say is “you are next in line”.

  4. Judy Scherer

    As one of the early adopter site leads in the AUA project in Alberta, I need to clarify that the early adopter sites applied to be part of the project, and were not necessarily one of the facilities with the highest antipsychotic use in the province. It was an amazingly successful project for the facility and for the Strategic Clinical Network. The goal was never to stop antipsychotic use, but to reduce the use to those that would benefit from the medication at the lowest possible dose. The same idea as we all do with antibiotics, there is a time and place for the medication. It is now a thoughtful process and is undertaken with a lot of discussion with family, resident, pharmacist, physician and nursing.

    • Andreas Laupacis

      Hi Judy. Thanks for your comment. You are right – many of the early adopter sites were high users, but not all. We have modified the article appropriately.

  5. Mark Kal

    Systemic issues in LTC are a major issue especially as the population ages and they are faced with older and more complex patients. Training will be key as funding for new staff is unlikely. However its important to note that some patients are appropriately treated with antipsychotics. Some care homes are stopping these medications without consulting families first resulting in negative outcomes. Given a system with fixed resources we need to find how to best use what we have and realize the public purse won’t likely be able to fund an ‘ideal’ situation. Clear discussions with families about the resources and options available including their risks/benefits and is the place to start. Its when these conversations don’t happen that problems arise.

    • Trish Rawsthorne

      With all due respect, if you don’t change the environment one lives in, you can’t expect them to accept in on or off inappropriate drugs. It is the inappropriate use of drugs that is the issue. Funding can be found, compassionate care cannot be bought, training needs to be mandatory however, as one educator stated, it is difficult to allow staff to attend sessions given the serious lack of staffing that has gone on for decades. There are legislative regulations for staffing requirements for child care, not so for elder care – why? The people who provide the majority of caretaking for the elderly in the community and in facilities are the family caregivers – where are the resources to support them? It costs on average $28/hour to provide additional support to residents paid by families, whereas the government allocates under $15/hour for health care aides who provide 90% of the care in nursing homes.
      Perhaps there are some administratively top heavy facilities that ought to be reviewed so that funding can be redirected where it will do the most good for the residents. People housed in nursing homes are residents not patients, as aging is not a disease that requires treatment, but a natural process that does not require the use of drugs in societies and countries that do not warehouse the elderly. This really says a lot about how a society values and cares for its elders.

      • Susan Macaulay

        “This really says a lot about how a society values and cares for its elders.”

        Precisely. You hit the nail on the head Trish.

  6. Denyse Lynch, Publisher Our Health Care, Our Choices

    Visiting a long term care home daily where my dad resided provided many opportunities for observing residents and staff interactions with them. The issues in LTC presented in this article cited for years were revealed in 2 task forces called for by the ON government in the last 8 years and are still ignored as the powers that be continue to study the issues.

    LTC support aides, PSWs spend the most time of the day with our loved ones assisting them in their daily living activities. From helping them get up in the morning to washing, dressing them – all activities residents can no longer perform for themselves – They see residents more than the medical staff and interact more frequently with them. So, they notice more, are knowledge workers capable of contributing to the quality of lives of residents.

    Yet their education, training for this role is “unregulated and not standardized” by the organizations who provide their certification. It is only recently Behavioural Support education and training has been made available to these support aides. My concern is the support aides are not included in “care conversations”, rather residents care is dictated to them by the medical professionals. Support aides have more insight, exposure to residents’ behaviours and emotional status due to having the most interactions, contact with the residents .

    The above suggestions: “individualized care plans through family consultations and team problem solving, needs to include support workers; alignment between patients’ goals of care and service delivery, improving the environmental and psychosocial support that residents require requires inclusion of support workers and all staff.

    The LTC culture needs to also include the activities and recreation staff as they play a big role in the planning of social and environmental interventions. Activities need to include providing more structure to a patient’s day, scheduling events to adjust to residents’ needs. Support workers can contribute here as they can consult to “Activities Staff” share what they observe with residents’ behaviours and assist staff in choosing an activity more suited to an agitated resident that he or she would enjoy more.

    The above article’s recommended 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, are all competencies, (a cluster of knowledge, skills and attitudes) called Communication, Interpersonal skills that can be taught. All of these techniques are evidence-based, because they are actions, behaviours, words that can be observed and measured and improved upon by coaching and or training of all staff.

    What I observed over 5 years is these competencies for “all” service providers, including medical professionals in LTC homes is hit and miss. Inherrent in some individuals, they either possess or don’t possess these competencies. This is one reason why the level of performance in LTC homes varies to the degree it does. This is why family caregivers, when they arrive to visit their loved ones want to know who is on duty – that prepares them for how vigilant they have to be with staff on that shift. This is why caregivers are burnt out in frustration with LTC homes.

    While I did my best for my dad, to provide feedback to LTC Directors Of Care and Administrators, staff training in improving the “human dimension” of quality care, the best I could do was to be at the home daily to ensure his comfort and quality of life.

    Until LTC homes review how they currently provide quality care, define what they mean by “quality”, (which I define as consistent adherence to standards), define their standards so as to be measurable (evident) how all their processes from setting objectives to – recruiting, hiring, training, compensation/rewards, IT processes “align” to truly reflect a resident-focused system this oft over-used word in the context of health care is just a “word”.

    • Trish Rawsthorne

      “This is why family caregivers, when they arrive to visit their loved ones want to know who is on duty – that prepares them for how vigilant they have to be with staff on that shift. This is why caregivers are burnt out in frustration with LTC homes. While I did my best for my dad, to provide feedback to LTC Directors Of Care and Administrators, staff training in improving the “human dimension” of quality care, the best I could do was to be at the home daily to ensure his comfort and quality of life.”
      Amen to these observations and many others in your comments. I have too been so exhausted after a visit to the LTC facility, it takes a lot of energy to be vigilant and always be on guard.
      I, too, have provided feedback to the facility managers and made some suggestions as well as pointed out omissions and errors but these were all met with a simple nod and a smile and never any communication back to me even though I am there more often than some of their part time employees.
      No one communicates with anyone – not nurses to doctors, not nurses to health care aides, not health aides to nurses. Rarely do I see any physical contact with residents ever – no hand holding, no gentle stroking of the back or arm. The nurses might go to an educational session once in a while but the aides who are the backbone of the facility, they can’t be allowed to attend anything longer than an hour, otherwise who is left to provide care.
      There is an issue with accreditation of these facilities, especially if the accreditors are their employers. This does not happen in hospitals as an outside accreditation team comes in to inspect the facility. If you were to ask family caregivers whether the facility met the standards, they would probably provide you with a more accurate rating.

  7. Evan Mitchell

    I am a graduate of Trent University’s honours psychology program and I am currently in my fourth and final year of Trent University’s honours nursing program. I am contributing to this discussion to provide readers with the perspective of a nursing student with 10 months experience working in long-term care (LTC) facilities.
    The article understates the severity of this major problem of prescribing antipsychotic medications to older adults living in LTC facilities. As stated, antipsychotic use is at approximately 29% in long-term care facilities. The medications that are most commonly prescribed are Abilify, Seroquel and Zyprexa. What is most salient is that none of these medications are indicated for the treatment of dementia-related psychosis and each one of these products’ monographs carry a black box warning stating that elderly people receiving these medications are at an increased risk of death (all cause) in comparison to placebo. Therefore, these medications are posing an immediate harm to older adults.
    These medications are only indicated for bipolar disorders and schizophrenia and, as bipolar disorder and schizophrenia have a prevalence of approximately 2.5 percent and 1 percent respectively, these medications are being prescribed for off label indications. As concerned parties such as health care workers and future caregivers it is clear that Ontario LTC facilities as a whole need to immediately adopt a “least antipsychotic approach” practice standard and this process can be accelerated by appointing a task force to educate and direct HCP’s that work with this population to reduce the over prescription of these drugs.

    Sincerely,
    Evan Mitchell
    Trent University

  8. Verdeen Bueckert and Mollie Cole

    What is hopeful about the Appropriate Use of Antipsychotics project in Alberta is the transformation that has occurred over the past year. As the drugs are withdrawn, residents become more alert. They become more able to relate to other residents and to staff, engage in activities and necessary care can be provided. The culture is shifting, and with it, family satisfaction and staff enjoyment of their work. If anyone needs hope that people care and are working to make a real difference, check out the “Coming Alive” video, and other success stories on our AUA Toolkit.

  9. Bob lawrence

    My wife has been in a long term facility for two years. She has alzheimers and is now being prescribed antipsychotic drug abilify. She is also on an anti-aggression drug. Prior to her being prescribed thes drugs, she spent most of the day circulating around her wing and the neighbouring unit. I was told approximately one year ago that she had become aggressive and was a potential threat to other residents and staff. She is now extremely tired and incoherent, uncooperative with staff, when it comes to dressing, washing and other personal needs. I have expressed my concern on these medications, however the best response I received was from the doctor, i quote. ARE YOU A DOCTOR. When is health Canada going to make a strong position on this serious problem. My wife is in an Ontario LTC.

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