As health care providers working in long-term care (LTC), we’ve seen firsthand how antipsychotic medications are prescribed to residents, and why. Antipsychotics are often used to help manage behaviors such as agitation and aggression in older adults living with dementia. They may be helpful for some patients, but antipsychotics can do more harm than good for many, especially when used long-term.
Now a new report has highlighted this as a concerning trend: one in four LTC residents in Canada is taking an antipsychotic medication potentially unnecessarily. This number has been increasing over time.
It’s time we reversed the trend.
The report, using data from the Canadian Institute for Health Information (CIHI), found Canada’s national rate of antipsychotic use without a diagnosis of psychosis among LTC residents, which had previously dropped to 20 percent before the COVID-19 pandemic, has climbed back to 24 percent.
These drugs come with serious risks, including strokes, falls, fractures, and even an increased rate of death. With every province and territory experiencing an increase of at least two percent following the pandemic, it’s clear antipsychotic use in Canada is heading in the wrong direction.
Antipsychotics should never be used without first doing a deep dive into understanding the meaning behind why behaviors might be happening and trying non-antipsychotic approaches first, like addressing pain or using music to help LTC residents feel calm and safe.
Canada has one of the highest rates of potentially inappropriate antipsychotic use among comparable countries, with a national rate of 24 percent compared to the United States at 10 percent, and Australia at 18 percent.
The national snapshot also doesn’t tell the whole story. Canada’s use of these medications varies across every province and territory, and even down to the individual LTC home level. In other words, some regions have rates significantly higher than the national 24 percent prescribing rate.
Caring for our most vulnerable older adults in LTC must be done differently. We’ve successfully tackled high rates of antipsychotic prescribing before, and we must do it again.
Before the COVID-19 pandemic, many LTC homes across Canada had effectively lowered their potentially inappropriate antipsychotic rates by focusing on person-centered approaches to care. This involves dementia care education focusing on knowing the history of the residents, including their preferences and routines.
Homes were supported to use available resources and tools to gain a deeper understanding of why distressing behaviors were occurring amongst residents in the first place, to support their deprescribing efforts.
While all of the reasons for the rising rates of antipsychotic prescribing are not yet clear, the COVID-19 pandemic clearly contributed. During the global pandemic, we know the priorities of LTC homes had to shift away from a person-centered approach to focus on the isolation of symptomatic residents to prevent the spread of the virus and ensure the safety of all residents.
Many staff in homes felt that this approach didn’t feel very person-centered. Staff turnover was a significant problem as well, with staffing shortages leading to reduced time to complete caregiving tasks and caregivers who did not know residents as well.
Regardless of the reasons that brought us to this place, this is where we are now, and it is time to get back to working toward quality improvements in care.
The rising trend in antipsychotic prescribing should serve as a wake-up call. We’ve already seen that real change is possible when care teams come together and have tools and supports to focus on the whole person.
So, what should be done now?
The report calls for a coordinated national response, including setting goals for LTC homes and supporting homes with quality improvement programs. These are necessary first steps in refocusing our attention to protect one of Canada’s’ most vulnerable populations.
Tackling this issue isn’t just about reducing antipsychotic medication use—it’s about ensuring every resident receives the best quality care, which is what we all strive for. Even in a system under strain, we can choose to do better.
Sid Feldman is a family and long-term care physician. Julie Weir is a registered nurse.
