For residents of Ontario’s long-term care homes, antipsychotic medications may play an important role in managing the behavioural symptoms that sometimes occur with psychosis or dementia, such as agitation and aggression. But the use of these medications has sparked controversy across the province, the country and around the world because of side effects such as sedation, higher risk of falls and slightly increased risk of death.
Family members of long-term care home residents may also see their loved ones struggling to communicate or sleeping for large parts of the day as a result of antipsychotic medication use. Without the drugs, however, some residents and their families might suffer because of behaviours that put them or others at risk.
The goal of this report is to generate an informed conversation about the complex issue of antipsychotic medication use in the province’s long-term care homes. To do this, we used available data to estimate the percentage of long-term care residents in Ontario who were using an antipsychotic medication, looked at whether that percentage has changed over time and examined whether antipsychotic medication use varied by region, by long-term care home, or by resident condition.
Across Ontario, there has been a slight decrease over four years in the overall percentage of long-term care home residents using an antipsychotic medication, from 32.1% in 2010 to 28.8% in 2013, but this finding does not tell the whole story. There is wide variation in the proportion of residents using an antipsychotic medication across long-term care homes, from no residents in some to more than 60% in others. Some of the differences can be explained by the fact that different homes care for different types of residents. For example, a home that cares primarily for residents with psychosis, dementia and mental illness may have a very high proportion of residents using antipsychotic medications.
Findings suggest that there are opportunities for homes to examine and compare their antipsychotic medication use, and to re-evaluate prescribing decisions to help individual residents achieve the best possible quality of life. Most people working in the long-term care community are aware of the benefits, risks and challenges associated with antipsychotic medications. Many have launched efforts to look more closely at the use of these drugs in their residents. Care teams at some homes have succeeded in reducing antipsychotic medication use by examining prescription data, reviewing individual residents’ conditions and behaviours, engaging families and caregivers, and making non-drug changes in care. These initiatives may affect how many residents use antipsychotic medications in Ontario.
Weaving together data and the real-life experiences of residents, family members, caregivers and long-term care home teams, this report sheds further light on antipsychotic medication use in the province’s long-term care homes.
Antipsychotic medications: Benefits, risks and challenges
For some residents of Ontario’s long-term care homes, antipsychotic medications improve quality of life and reduce suffering. But for others, these drugs may bring more risks than benefits. With this report, we aim to stimulate a conversation about an important issue that affects many Ontarians.
Why are antipsychotic medications prescribed?
Antipsychotic medications are often used to treat psychosis, a term used to describe the hallucinations and other behaviours that frequently occur in people with conditions such as schizophrenia and bipolar disorder. These medications may also be effective at relieving symptoms such as agitation and aggression, and can improve quality of life in people with dementia.
Antipsychotic medication use in long-term care homes
The use of antipsychotic medications in people over age 65 has been a medical and political issue for decades, not only in Ontario, but around the world. It is particularly relevant for Ontario’s more than 600 long-term care homes, where residents are often old, frail and need around-the-clock care. Many experts are concerned about the use of antipsychotic medications because of their side effects. The drugs can cause people to lose their energy and motivation, and to feel drowsy. These symptoms can seriously affect people’s quality of life and make it difficult for family members to communicate with their loved ones. Antipsychotic medications also appear to increase the risk of stroke, pneumonia, heart disease, kidney injury, diabetes and falls. Furthermore, older adults with dementia using certain antipsychotic drugs have a slightly higher chance of dying than those prescribed a placebo. A 2007 study found that in Ontario, there was substantial variation from home to home in the percentage of residents with a prescription for an antipsychotic medication.
The focus of this report
To gain more insight into the current state of antipsychotic medication use in Ontario, we have addressed the following questions:
• What is the percentage of Ontario long-term care home residents who are using an antipsychotic medication, and has that percentage changed over the last few years?
• Is the percentage of residents using an antipsychotic medication similar between regions and across long-term care homes?
• What percentage of residents with psychosis or dementia use antipsychotic medications, and has his percentage changed over time?
In this report, we have looked at antipsychotic medication use in Ontario long-term care homes by determining the percentage of residents who had a filled prescription for an antipsychotic medication. Although this method does not guarantee that all residents with a prescription are actually using these medications, it is as close as we can get to assessing medication use with the data that are available.
Work underway in Ontario to optimize treatment
Given the risks related to antipsychotic medication use, most experts recommend first trying nondrug interventions to treat behavioural symptoms in long-term care residents. Making sure residents are not uncomfortable, hungry or in pain, adjusting their surroundings, and introducing social activities such as exercise programs or music therapy may reduce the need for antipsychotic medications. Only after these treatments fail to improve behavioural symptoms should antipsychotic drugs be prescribed.
Joseph’s move to a long-term care home
When it became too difficult for his family to support him at home, Joseph was admitted to a long-term care home. He was suspicious of his caregivers and would sometimes try to hit them while they were helping him bathe or change his clothes. He also pushed other residents in the hallways if they were in his way. Joseph’s care team tried to address these behaviours by making sure he was aware of what they needed to do to care for him, and by providing a calm atmosphere. But his physical aggression continued. Joseph’s doctor prescribed him a small dose of an antipsychotic medication—just enough to reduce his suspicion and aggressive behaviours.
Angela’s hospital stay
Angela, a long-term care home resident, became confused and disoriented while she was being treated in hospital for a serious blood infection. She tried to pull out her intravenous line and hit a nurse who was caring for her. Angela was prescribed antipsychotic medication during her hospital stay so that the treatment she needed could continue. After she returned to the long-term care home, Angela’s confusion resolved, and her aggressive behaviours stopped. The home’s doctor was then able to taper her off the medication.
Mary and her daughters
When she was still living at home, a psychiatrist had prescribed Mary an antipsychotic medication because she had been experiencing outbursts of screaming. While the medication appeared to help with the yelling, Mary’s daughter Benny noticed other changes as well. “We lost the emotions,” Benny said. “She would be sleeping all the time. She just wasn’t there.” Nevertheless, Mary continued to use the medication through
two years of supportive care after breaking her hip, and for several months after moving into a long-term care home. Mary spent many of her days at the long-term care home in a deep sleep. When she was awake, she did not talk. After a careful assessment and consultations with Mary’s three daughters, doctors at the home decided to reduce and eventually stop her antipsychotic medication. Mary began to perk up immediately, smiling and laughing. “We got that little moment back with her,” Benny said. “Her eyes were always so bright and sparkly, and it was like she was back.” Although stopping the medication appeared to make Mary more alert, it also led to new challenges for the family as they saw their mother struggle to think and communicate. “Sometimes you’d walk out angry,”
Benny said. “Other times, it was wonderful to walk in and see her smiling, laughing and enjoying some of her tablemates. There were truly mixed emotions.” One day, Mary was able to go to her daughter Paula’s house for a family lunch. “Mom was smiling and excited,” Benny recalled. “She looked at Paula and said, ‘I love you.’ Paula beamed with excitement, saying ‘I love you more.’” It was the first time in years that they had heard their mother speak. Mary and Benny appear on the cover of this report.
Nearly one-third of Ontario long-term care home residents were prescribed antipsychotic medications.
Changes for the better
Sherly is a personal support worker at a long-term care home in Etobicoke
Sherly noticed a change in some of the residents almost immediately when their antipsychotic medications were reduced or stopped. She says she saw them walking around and able to describe the things they wanted. “There were times when residents resisted care a little bit, but nothing we couldn’t handle,” Sherly said.
Caroline, the director of nursing care at the same home, was convinced they could help residents live quality lives without relying on antipsychotic medications, and in January 2014 she and her team launched a plan they hoped would lead to a reduction in the use of these drugs. By conducting a detailed patient-by-patient review of current cases, making non-drug changes to care and providing education programs for team members about the benefits and risks of antipsychotic medications, the percentage of residents using these drugs decreased by nearly half — from 32% to 17% — after three months. “I would like to see antipsychotic medication use in older adults become the exception,” Caroline said. Consultant pharmacist Bella, who also worked with the team at the home, said she hoped to see a significant decrease in the use of antipsychotic medications to “provide the mental clarity that can lead to better resident quality of life.” The personal support workers were supportive of the program, according to Sherly. “You can interact with the residents now,” she said. “You can see them go and play bingo, that kind of thing—even to let us know they need to go to the bathroom.” Paolo, one of the residents in Sherly’s care, became much more animated after he was weaned off antipsychotic medications. “Before, he didn’t want to do anything,” Sherly said. “He was always tired. He didn’t want to eat—he would just sit and look at the food, very confused. But now, I see big changes. When I go in, he is the first one to say, ‘Hi, good morning! How are you today?’ and ‘It’s good to see you.’”
One simple question
Simon, Executive Director at a long-term care home in the Ottawa area
Simon noticed some of the residents were much more alert than they had been in recent months. As he strolled through the dining room, he saw a man in his 80s holding his daughter’s hand and telling her about his bingo game that morning. The next table over, a woman in her 70s was smiling and laughing as her granddaughter told a joke. Two months earlier, the home had launched a quality improvement plan to reduce antipsychotic medication use among its residents. “Their quality of life improved greatly,” Simon said. “Before, people would come and visit and there wasn’t a lot of interaction. But now, there’s that new level of communication.” Working with a team of eight doctors, the home’s medical director took 10 random charts, reviewed them with a nurse practitioner and held a meeting with the doctor and care team assigned to each resident.
For each resident, the goal was to answer one simple question: why was this antipsychotic medication prescribed? The program worked. Half of the residents in the review had their antipsychotic medications reduced or discontinued. In each case, the resident was re-evaluated to see if the medication could be reduced further or eliminated. The team found that it was easier to reduce or stop antipsychotic medications for residents who were on them for a shorter period of time. The care team complemented this process with best practices and other behaviour management strategies to help those with dementia and/or aggressive behaviour. There were a few challenges during the process, Simon noted. Among residents who had been prescribed antipsychotic medications for a decade or longer, doctors found it more difficult to discontinue the medications completely. If the residents had recurring problems with aggressive behaviour, the antipsychotic medication might be reduced, but not stopped. “If somebody is really agitated or upset, that is not a great quality of life, either,” Simon said. The second issue was getting residents’ families on board. Simon says it was essential to involve the families in the process. “They might say, ‘Mom was on this forever – why are we taking this away?’
We need to shift the paradigm to have the families say, ‘Why is my loved one on this medication?’” Simon said. “Families are more informed now.” Some care team members and families were afraid of repercussions such as aggressive behaviour if the antipsychotic medication was stopped, but there were no major incidents, Simon said. In fact, after positive results in the original small group of 10 residents, the organization rolled out the program across its two long-term care homes, which housed a total of more than 250 residents.
Reprinted with permission from Health Quality Ontario. References available upon request.