Earlier this month, Health Canada announced new restrictions on the prescribing of risperidone, an antipsychotic drug commonly given to dementia patients to control aggression and other behaviour problems.
The news didn't receive any fanfare, possibly because it doesn't appear to represent any significant change. According to the announcement, doctors are being told to only prescribe risperidone to patients with severe Alzheimer's disease for the short-term management of aggression or psychotic episodes. Before, the drug was approved for use in any patient with severe dementia for any length of time.
Health Canada says the restrictions were put in place because a safety review showed the drug can put patients at a higher risk of stroke and other cerebrovascular problems. Risperidone belongs to the second-generation class of atypical antipsychotic drugs that came on the market during the 1990s and became a popular choice because they were believed to be safer than older antipsychotics.
Here's what the announcement doesn't say: that antipsychotics are being prescribed far too often to seniors with dementia, even though most of those drugs were never approved for that purpose and plenty of evidence shows they can cause dangerous, life-threatening side effects, including heart problems and deadly falls.
Among people with dementia, the vast majority of antipsychotic prescriptions go to people living in long-term care facilities. A 2009 study from the Canadian Institute for Health Information found that about 38 per cent of long-term care residents in Manitoba, New Brunswick and Prince Edward Island were on antipsychotics compared with less than 3 per cent of seniors in the community. Reports and research from across the country show that in some long-term care institutions, no consent was given before seniors were placed on antipsychotic medications. In other cases, the drugs aren't used to treat patients who are severely aggressive or agitated, but to sedate individuals so they are less of a burden to staff.
People living in long-term care facilities are an extremely vulnerable, but often hidden, segment of society. Unless you have a relative living in an institution or work in one yourself, the serious problems that can go on inside often remain concealed.
These individuals deserve better. And the need for better treatment, staff training, non-pharmacologic interventions and other effective strategies will only become more pressing as the number of Canadians with dementia increases.
Despite their widespread use, few antipsychotic drugs have actually been approved for use in people with dementia. In Canada, only risperidone has that distinction. The rest are prescribed "off label," which is perfectly legal, but is prompting some medical experts to raise concerns, particularly as the evidence of serious side effects continues to emerge.
For instance, a 2012 U.S. study published in the British Medical Journal found that long-term care residents taking certain antipsychotic drugs to treat dementia symptoms faced twice the risk of death compared with residents not on those drugs.
Given the dangers, last year two British dementia researchers wrote a paper in the BMJ that calls on doctors to stop prescribing antipsychotics to routinely treat agitation and aggression in dementia patients.
There has been growing discussion among provinces and health-care institutions about alternative treatments that could help dementia patients manage their symptoms, such as behavioural therapy or better training for staff.
But a Canadian study published in JAMA Internal Medicine in 2007 led by Dr. Paula Rochon, a scientist at Toronto's Women's College Research Institute, suggests an institution's reliance on antipsychotics may depend greatly on internal culture. The study found that seniors living in long-term care facilities with high antipsychotic prescribing rates were three times more likely to be put on the drugs compared with people who lived in homes with low prescribing rates.
There's no arguing over the fact that some dementia patients can pose a major challenge and that in severe instances, such as cases where they pose a threat to themselves or others, antipsychotics may help. But otherwise, they should be used with caution in older adults, Rochon says. Far too many institutions are trying to solve this problem with pills, even though it's clear that in many patients, antipsychotic drugs aren't very effective and can expose them to risk. Seniors deserve to be treated with dignity and it's time provincial governments and long-term-care institutions take real action to stop the unnecessary use of pharmaceuticals.