Care homes vary wildly in prescription of antipsychotics, study finds

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Wild variations in the number of residents in long-term care who are prescribed antipsychotic medications are focusing new attention on how and why these powerful drugs, which can have serious side effects, are used so routinely.

A study of 604 long-term-care homes in Ontario, to be released Wednesday, found that anywhere from zero to 67 per cent of residents over the age of 65 are treated with antipsychotics after a diagnosis of psychosis, dementia or other conditions that can leave them highly agitated.

While the drugs are calming, the side effects include a higher risk of falls, profound drowsiness, lessened quality of life, and a slightly increased risk of death. There are even complaints that the drugs are used to "chemically restrain" patients in long-term care.

But Joshua Tepper, president and CEO of Health Quality Ontario which conducted the study, said it's not as simple as saying the drugs are overused.

"There probably isn't a 'right' number, but when you're going from zero to 67, it's too broad a variation," he said. "In some homes, the number is probably too high, in some it may be too low, but it really depends on the condition of the residents."

The study, entitled "Looking For Balance", was conducted in Ontario, but patterns of prescription for antipsychotics are similar in other provinces.

"Every jurisdiction is struggling with this issue," Dr. Tepper said.

Researchers examined data from 57,405 residents of publicly funded long-term-care homes, 70 per cent of whom have a diagnosis of dementia, 18 per cent with a diagnosis of psychosis and 12 per cent with neither condition.

Analysis of the data showed that antipsychotics were prescribed to 47 per cent of residents with psychosis, 27 per cent of those with dementia and 12 per cent with neither condition.

It is the prescription of antipsychotic medication to people suffering from Alzheimer's and other forms of dementia that is most controversial.

"In the U.S., there is no indication for these drugs for dementia, but in Canada it is fairly common," Dr. Tepper said.

The good news is that, over all, prescriptions of antipsychotics are dropping even though there are more people institutionalized and rates of dementia and psychosis are rising.

In Ontario, the number has dropped to 29 per cent from 32 per cent in four years. The report features a number of stories of patients and homes that show, anecdotally, the benefits and harms of antipsychotics:

• Mary began experiencing outbursts of screaming. She was prescribed antipsychotics and became near catatonic, sleeping all day.
• Angela became disoriented when she was transferred from a long-term-care home to hospital for treatment of a serious blood infection. She pulled out intravenous tubes and struck nurses, so she was prescribed an antipsychotic. When she returned to the home, her confusion ended, and the medication was stopped.
• The pharmacist at an Etobicoke nursing home, concerned by the research, set out to lower antipsychotic use and cut the number of patients using the drugs to 17 per cent from 32 per cent. Support workers reported that patients were more lively, alert and easier to deal with.
• The director of an Ottawa long-term-home ordered a case-by-case review of each patient’s prescriptions, and the result was a 50-per-cent drop in antipsychotic use. Residents and family members said quality of life improved significantly.

Dr. Tepper said the lesson to take from the data and the stories is that it's essential to individualize treatment, "to make sure you use the right approach for that person."

He said family members – who are often substitute decision-makers for patients with dementia and psychosis – and their caregivers should focus on the symptoms they want to manage, and then figure out how best to manage them, either with medication or other non-medicinal treatments.

"Some patients get extremely agitated and confused and they can hurt themselves and others," Dr. Tepper said. "You want to figure out how to best help them, and that should include a good, practical conversation about the pros and cons of medication."