Prescribing antipsychotics in long-term care homes: report

A recently released Health Quality Ontario (HQO) report prompts a welcome discourse about the circumstances in which antipsychotic medications are administered in long-term care, says Toronto health lawyer Mary Jane Dykeman.

Looking for Balance: Antipsychotic medication use in Ontario long-term care homes was released on May 20 and is a call to action for homes to examine and improve their prescribing practices, she tells

Dykeman, partner at Dykeman Dewhirst O’Brien LLP, teaches Mental Health Law in Osgoode’s Health Law LL.M. program and advises long-term care homes. She says the HQO report provides timely, evidence-based analysis and will precipitate further discussion.

The HQO team analyzed data for the three years between 2010-2013, based primarily on claims data available through the Ontario Drug Benefits program, which covers all long-term care residents in the province. HQO concluded that for those years, 18.3 per cent of residents prescribed antipsychotics received them for treatment of psychosis; roughly 69.6 per cent were residents with dementia but without psychosis; and 12.1 per cent of the drugs were prescribed to those who had neither psychosis nor dementia.

The report also provides a helpful snapshot about who lives in long-term care and their cognitive status: 79.1 per cent had some degree of cognitive impairment, while 28.3 per cent displayed severe impairment. Almost half of the residents in long-term care (or 47.1 per cent) had aggressive behaviours such as verbal or physical abuse, disruptive behaviours and resisting care; and 9.6 per cent exhibited severely aggressive behaviour.

However, reducing antipsychotics requires leadership, says Dykeman. The good news is that long-term care homes and physicians are supported by excellent work being done by their associations, and further work will be done by HQO and also nationally, she says.

Dykeman was part of a panel examining this issue at the 2014 convention of the Ontario Association of Non-Profit Homes and Services for Seniors. The panel was chaired by Dr. Ken Le Clair, co-director of the Centre for Studies in Aging and Health, Providence Care. It included lawyer and institutional advocate Jane Meadus of the Advocacy Centre for the Elderly, Dr. Andrea Moser, a prominent Baycrest geriatrician and president of the Ontario Long-Term Care Physicians, Dr. Joel Lexchin, a professor at York University’s School of Health Policy and Management, and Louis Charland, a bioethicist and professor at Western University's Departments of Philosophy and Psychiatry, School of Health Studies and Rotman Institute of Philosophy.

Dykeman says the prescribing of antipsychotics is an important societal issue, with tremendous impact on quality of life for residents in long-term care as well as their family members' peace of mind. For example, substitute decision-makers acting for an incapable resident in long-term care rely on the proposing physician to determine what treatments are optimal. At the same time, frontline staff in long-term care homes face real challenges in managing resident behaviours. Achieving a balance in prescribing that alleviates psychosis and behaviours that accompany some dementias while maximizing quality of life is not easy, but the HQO report highlights that some homes have tackled the issue, reduced prescribing of antipsychotics and are experiencing a measurable positive shift in resident experience.

“It is a fact that behavioural challenges exist in many long-term care settings, and certainly antipsychotic medications will be legitimately prescribed in some instances," says Dykeman. "However, they are not intended as a first offering or for all conditions, and consistent with the Health Care Consent Act framework in Ontario, consent of either the capable resident (or if incapable, the resident's substitute decision-maker) is required.

"This includes receiving information regarding the risks and benefits of, and alternatives to, the proposed treatment. It is also important for the proposing practitioner to know whether the antipsychotic is actually appropriate for the resident, given that a number of antipsychotics are not approved by Health Canada for use in the elderly with dementia; these drugs may be subject to what is referred to as a 'black box' warning by drug manufacturers and for that reason 'off label' use by health practitioners should be done with extreme care."

The HQO report confirms that in the three-year time frame examined, the prescribing of antipsychotics in long-term care is trending downward.

"Despite the aging demographic, this analysis shows that real change can occur,” says Dykeman.

Increased programming and activities, as well as the training and resources available through groups such as Behavioural Supports Ontario and the Alzheimer Society of Toronto can also make a difference in how staff manage difficult behaviours of residents, she says.

Dykeman notes that the discussion is ongoing: an expert panel has been convened to present on the topic at the Advocacy Centre for the Elderly's June 10 Biennial Special Lecture.

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