Long-term care: increase in antipsychotics administered without diagnosis

According to data from the Canadian Institute for Health Information (CIHI), antipsychotic drugs are prescribed without the patient having been diagnosed with psychosis. This type of use called off indication would sometimes be appropriate, according to experts, who are however concerned about the high rates of prescriptions of this type in certain residences.

Laura Pinto’s father was given the drug Haldol while a resident of a long-term care facility in Windsor. It is a drug whose main indication is the treatment of schizophrenia, but which can also be used for aggression and agitation in people who suffer from dementia.

Robert Pinto was passionate about teaching.

Photo: Image: Laura Pinto

However, a doctor has never determined that Mrs. Pinto’s father suffered from a psychiatric illness that these powerful drugs are supposed to treat.

As a result, she claims that during the year her father took the drug, his condition deteriorated from a man with dementia and memory problems to a ‘zombie’.

Antipsychotics are used off indication by tens of thousands of residents of long-term care centers across the country reveals a national survey by Radio-Canada / CBC. Their use is in constant decline, reaching their lowest level in 2019.

The most recent data from theHERE demonstrate that the trend has reversed during the COVID-19 pandemic.

Preliminary data for the year 2021-2022, provided by theHERE demonstrate that the upward trend is continuing and that the use potentially inappropriate for this year exceeds 23%.

The data is published by fiscal year from April 1 to March 31 of the following year. These do not include all residences for the elderly or long-term care. For the year 2020-2021, just over 1,300 residences, in 8 provinces and one Canadian territory, are included. No data is provided for Quebec, Prince Edward Island, Nova Scotia, Northwest Territories and Nunavut.

Nevertheless, the other provinces also collect data on the use of antipsychotics, using analysis models that are difficult to compare.

Quebec, for example, implemented the OPUS-AP program and determined, in a 2019 report, that 40-60% of residents of long-term care centers over the age of 65 take antipsychotic drugs without have been diagnosed or have received additional doses for a reason other than their diagnosis.

Use potentially inappropriate

The Canadian Institute for Health Information has published the report since 2015 Potentially inappropriate use of antipsychotics in long-term care.

The analysis of theHERE relates to the so-called use potentially inappropriatebecause use without diagnosis may be appropriate, beneficial, or necessary in certain situations.

Data like this is particularly important, according to the director of the geriatrics program at Sinai Health in Toronto, Samir Sinah. He claims that this information is patient voice who often suffer from cognitive difficulties that prevent them from claiming on their own.

Why prescribe them?

Dr. Alexandra Sammartino-Arbour, who specializes in the treatment of behavioral problems in people with cognitive impairment or dementia, points out that Health Canada recommends the use of antipsychotics to treat symptoms of dementia in certain circumstances, for example example when a patient exhibits aggressive behavior.

She says antipsychotics have also been used during the pandemic to enforce isolation [en raison de la] covid.

Behaviors that are increasingly difficult to manage in long-term care centers are one of the consequences of significant changes in the country’s demographics. According to the most recent Statistics Canada census, the population over the age of 85 has doubled in the country between 2001 and 2021 and older people often have more serious health problems.

Dr. Sammartino-Arbour points out, however, that these drugs have significant risks related to their side effects.

Possible side effects of antipsychotics

  • Decreased attention and memory
  • Drowsiness
  • Blood pressure drops
  • Increased risk of falls
  • Stiffness or tremors

According to recent studies, the risk of death from heart problems or infections is twice as high in patients prescribed antipsychotics. They also have a risk of stroke up to four times higher.

Health Excellence Canada (ESC) is conducting a national awareness campaign to encourage reductions in the use of antipsychotics by healthcare professionals.

In a publication intended for them, ESC claims that the drugs only mask the symptoms. Symptoms may seem to subside if [antipsychotiques] reassure the patient, but will return when a tolerance […] is reached.

Dr. Sammartino-Arbor declines to estimate what an appropriate or optimal utilization rate would be, but says that the quality of patient care is improved each time another tool is found that helps control symptoms or modify behaviors. She also points out that usage may differ between settings.

In hospitals, we end up with a use probably much higher than 20% because the patients are very sick and very agitated because of their illness. »

A quote from Dr. Alexandra Sammartino-Arbour, geriatrician

Although there does not seem to be any scientific consensus on an ideal rate of use, around ten experts consulted by CBC and Radio-Canada agree: current utilization rates are higher than they should be.

Dr George Heckman, who heads the research chair in geriatric medicine at the University of Waterloo, estimates that optimal use would likely affect 10% of residents in long-term care homes, just under half the rates current nationals.

Efforts to reduce the use

Like the implementation of the OPUS-AP program in Quebec, several provinces have adopted strategies in recent years to reduce the use of antipsychotics in long-term care centers.

British Columbia has exceeded the national average for years with usage reaching 26% in 2020-2021.

Health centers in Saskatchewan and Alberta, for example, have gradually increased the use of antipsychotics since 2017-2018.

Of the 275 centers in British Columbia for which theHERE obtained data, about 20 administered antipsychotics without a diagnosis to more than 40% of their residents.

Lawyer Melissa Myers, who represents families of residents of long-term care homes, believes the federal government should fulfill the promise made during the pandemic to put in place national standards for long-term care.

This is one of the reasons why we need national standards directly linked to federal funding. »

A quote from Melissa Myers, Lawyer
A woman is holding a photo book.

Laura Pinto had prepared a memory book for her father who suffered from dementia.

Photo: Radio-Canada

Shortly before his death in 2019, Laura Pinto’s father, Robert, had to be hospitalized with a respiratory infection.

During his stay, the doctors reduced his doses of medication and in particular the antipsychotics that were prescribed to him.

Laura Pinto says her father has changed. He still suffered from dementia, she says, but his appetite returned, his ability to recall certain memories and to love poetry too.

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