Long-Term Care: Increase in Antipsychotics Given Without Diagnosis

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Care long-term: rise in antipsychotics administered without diagnosis

The use of antipsychotics increases the risk of falls, cardiovascular events and death.

Strong tranquilizers are administered to more than one in five residents of long-term care facilities across the country, without them having received a diagnosis that justifies their use.

According 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-label would sometimes be appropriate, according to experts, who are concerned, however, about the high rates of prescriptions of this type in some 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.

However, a doctor never determined that Mrs. Pinto's father suffered 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, her condition improved. has deteriorated from a man with dementia and memory problems to a ''zombie''.

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

The latest data from CIHI shows that the trend has reversed during the COVID-19 pandemic .

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Preliminary data for the year 2021-2022, provided by CIHI, shows that the upward trend continues and that potentially inappropriate use 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, 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 homes over the age of 65 are taking antipsychotic medications without have received a diagnosis or have received additional doses for a reason other than their diagnosis.

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

Review the latest report from the Canadian Institute for Health Information

CIHI's analysis focuses on so-called potentially inappropriate use, because use without a diagnosis may be appropriate, beneficial or necessary in certain situations.

Data are particularly important, according to the director of the geriatrics program at Sinai Health in Toronto, Samir Sinah. He says this information is the voice of patients who often suffer from cognitive difficulties that prevent them from self-advocating.

Dr. Alexandra Sammartino-Arbour, who specializes in treating 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, such as example when a patient exhibits aggressive behavior.

She says antipsychotics have also been used during the pandemic to enforce isolation [due to] COVID.

The increasingly difficult behaviors in long-term care centers are one of the consequences of major changes in the country's demographics. According to the most recent census from Statistics Canada, 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.

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

  • Impaired attention and memory
  • Drowsiness
  • Lowers in blood pressure
  • Increased risk of falls
  • Rigidity 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 an up to four times greater risk of stroke.

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

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

Dr. Sammartino-Arbor refuses to estimate what an appropriate or optimal rate of use would be, but asserts that the quality of patient care improves every time another tool is found that helps control symptoms or modify behaviors. It also points out that usage may differ between settings.

“In the hospital setting, you end up with probably much more than 20% utilization because the patients are very sick and very agitated because of their illness.

— Dr. Alexandra Sammartino-Arbour, Geriatrician

While there does not seem to be a scientific consensus on an ideal usage rate, a dozen experts consulted by CBC and Radio-Canada agree: current usage rates are higher than they should be. being.

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 centers, just under half of current national rates.

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.

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British Columbia has exceeded the national average for years with usage reaching 26% in 2020-21.

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 CIHI has obtained data, about 20 have 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 reason why we need national standards directly tied to federal funding. »

— Melissa Myers, Lawyer

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

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 prescribed to him.

Laura Pinto says that 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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