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Question: My mother has dementia and lives in a long-term care home. She was put on an antipsychotic drug because she was hard to control. I’m worried about her. She seems zonked out all the time. Is there another option?
Answer: It’s fairly common – maybe too common – for dementia patients to be given antipsychotic medications.
The drugs were originally developed for people with schizophrenia and other disorders that produce psychotic symptoms, such as visual and auditory hallucinations.
Because dementia patients can also have hallucinations, doctors began prescribing antipsychotic medications to dementia patients who suffer from psychotic episodes or exhibit other troubling behaviour such as aggression and agitation.
However, a growing body of research now suggests that prolonged use of antipsychotic drugs can pose risks to patients, including slightly increasing the chance of developing electrical abnormalities in the heart or causing rigid movements resembling Parkinson’s disease.
What’s more, patients taking these drugs face an elevated chance of death from all causes, compared to those who are not on them, says Dr. Barbara Liu, a geriatrician at Sunnybrook Health Sciences Centre.
The reason for the elevated risk of death isn’t entirely clear. But it’s possible that the effects on the heart or the sedation caused by the medication leads to a host of health problems, ranging from bedsores to catastrophic falls.
To minimize the risks, the drugs should be used only under limited circumstances, such as:
- The patient poses a risk to self or others.
- The behaviour is preventing essential medical care from being delivered.
- The patient appears to be suffering as a result of the delusions and hallucinations.
Medication can be helpful in some patients, but other approaches should always be tried first, says Liu.
She notes aggression or agitation can be an expression of an “unmet need.”
In the moderate to severe stages of dementia, patients may lose their ability to communicate. They might be in pain, hungry, bored or have any number of other complaints, but be unable to tell anyone what’s bothering them.
“We need to know what’s the root cause of the behaviour,” says Liu, who is also the Executive Director of the Regional Geriatric Program of Toronto.
Family members can sometimes help healthcare providers figure out what’s troubling a patient, says Dr. Ilan Fischler, Physician-In-Chief at the Ontario Shores Centre for Mental Health Sciences in Whitby, Ont.
He points to the example of an elderly man who is a very private person and feels uncomfortable being seen naked. Family might be able to explain why the patient starts “hitting out” whenever staff tries to take off his clothes – and possibly suggest strategies to improve the delivery of personal care.
Of course, there will be times when the best efforts fail to ease the patient’s distress or reduce the risk of harm to self and others, and in these situations a medication is an appropriate option, says Fischler. But, he adds, that doesn’t mean a patient should remain on the drug forever. After a period of time, “you should try weaning them off the medication and see how they do.”
Unfortunately, some patients are put on the drugs and left on them indefinitely.
There are wide variations in the use of antipsychotic medications in Ontario’s long-term care homes, according to a study published last year by Health Quality Ontario (HQO), a provincial agency with a mandate to improve the health-care system.
In some facilities, the drugs are not used at all, while in others up to two-thirds of the residents are prescribed them. Some of this variation could be due to the fact that certain homes have a relatively high percentage of residents with severe mental illnesses or advanced dementia, says Dr. Joshua Tepper, HQO’s CEO. But it may also reflect a lack of staff awareness and training in alternative ways to care for patients.
“We deeply believe that we can do better and, in fact, we have seen a drop in the use of antipsychotics and physical restraints,” says Tepper. HQO recently released new quality standards for dealing with the behavioral symptoms of dementia. The standards suggest that a patient’s medication should be regularly reviewed to see if the dosage can be reduced or the drug stopped altogether.
Across Canada, other provinces are also attempting to lessen the reliance on antipsychotics. Alberta, in particular, has made huge strides.
In 2011-2012, about 26.8 percent of the residents in Alberta’s long-term care homes were prescribed these medications – lower than the national average of 30 percent at such facilities.
Alberta was able to further reduce medication by providing staff with specialized training at a series of workshops.
“This project was really about helping the teams feel safe taking people off antipsychotics – and confident that disastrous things were not going to happen,” says Mollie Cole, an Advance Practice Nurse and co-leader of the project in her role as Manager of the Seniors Health Strategic Clinical Network for Alberta Health Services.
Staff were encouraged to start with a gradual dose reduction on a few patients who didn’t seem to need the drugs anymore and then observe what happened. Most of the time, there was no immediate change in the person. In five to 10 percent of patients, the troublesome behaviors returned and they had to be put back on the drugs.
In the vast majority of cases, however, the residents gradually began to “wake up,” says Cole. “They were better able to connect with their environment – they weren’t sleeping all the time,” she explains. “We even had people who started playing a musical instrument again or knitting again.”
With each success, more and more patients were slowly weaned off the drugs. According to the latest figures, only about 18 percent of the residents in Alberta’s long-term care homes are now on these drugs. That’s the lowest rate in Canada.
Cole believes that additional reductions can still be achieved. Even those patients who were put back on the drugs may eventually not need them. “We know that dementia changes over time and the hallucinations and delusions may resolve on their own.” Every few months, these cases will be reviewed and a dose reduction may be tried once more. “We are going to keep working at it,” says Cole.
Alberta’s example shows that it is possible to significantly cut back on the inappropriate use of antipsychotics. Staff training appears to be a key catalyst for change.
Getting back to your question, if you think your mother is being medicated inappropriately, ask the staff to review her case. A trial dose reduction may reveal she no longer needs the drug.
Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.