Antipsychotic Use Rose During Pandemic

A healthcare worker hands someone a pill and water

After years of progress, the pandemic saw increase in potentially inappropriate use of antipsychotics in long-term care homes

Antipsychotic use was on a steady decline in recent years due to efforts to address behavioural and psychological symptoms of dementia by other means. Recent data, however, show that prescribing rates have increased in several provinces, including Ontario, during the COVID-19 pandemic.

What’s behind this rise, what does it reveal about conditions in long-term care (LTC) homes and how might this trend be reversed? That was the topic of a recent Choosing Wisely Canada webinar.

“This is a challenge we really need to take up again in order to see those gains we were making before the pandemic,” said Dr. Nathan Stall, Geriatrician at Sinai Health System and the University Health Network Hospitals.

Potentially inappropriate use of antipsychotics in LTC residents dropped by 26 percent between 2014–2015 and 2019–2020 nationwide.

The rate of antipsychotic use without a diagnosis of psychosis dropped from 27 percent in 2014–2015 to 20 percent in 2019–2020, which is equivalent to 37,500 fewer residents being prescribed antipsychotics in 2019–2020 compared with 2014–2015.

Primary causes were likely prolonged social isolation produced by infection prevention and control measures, and staff shortages.

During the pandemic, however, the numbers crept up in some provinces. Rates of antipsychotic use increased slightly in Ontario, Alberta and British Columbia in 2020–2021 compared with 2019–2020, while they decreased slightly in Newfoundland and Labrador.

According to Ontario statistics from the Canadian Institute for Health Information (CIHI), the potentially inappropriate use of an antipsychotic in long-term care residents was 18.3 percent in 2019-20; 19.3 percent in 2020-21 and 21.1 percent in 2021-2022.

The most common antipsychotic medications among LTC residents without psychosis were quetiapine and risperidone, representing more than 70 percent of prescriptions.

The Choosing Wisely Canada panel of experts agreed the reasons for the increase were complex and multi-factorial, but primary causes were likely prolonged social isolation produced by infection prevention and control measures, and staff shortages. The circumstances of the pandemic, said Dr. Stall, saw clinicians less likely to prioritize favourable, nonpharmacological management for issues such as aggressive and agitated behaviours.

“Like many a pandemic casualty, the urgency to respond to immediate needs likely dwarfed everything else,” he said.

Antipsychotic medications are sometimes used to manage behavioural symptoms associated with dementia, but they can have harmful side effects, including drowsiness, increased confusion and physical changes. In many cases, behavioural interventions can help address those symptoms that often accompany memory impairment, such as depression, wandering, agitation or aggression, and reduce the need for medication. Some examples of behavioural interventions are physical or mental exercises, engaging socially or learning ways to compensate.

The panel discussed some of the available tools to support how physicians understand, assess and manage residents with responsive behaviours, with a focus on antipsychotic medications. One of the tools cited was the Centre for Effective Practice’s (CEP) “Academic Detailing for Long-Term Care Homes.”

The tool’s key principles in prescribing antipsychotic medications include:

  • Being resident-centred;
  • Being mindful of benefits, risks and safety concerns;
  • Using an interprofessional team approach and validated tools;
  • Prescribing conservatively; and
  • Reassessing regularly for opportunities to deprescribe medications that are no longer needed.

“As always, efforts must be made to individualize any treatment decisions for the resident, with consideration given to caregivers, family members, as well as LTC staff,” states the introduction to the tool.

Dr. Andrea Moser, a family physician at Baycrest Geriatric Health Sciences, agreed with CEP’s emphasis for a team-approach to resident care. Regular consultation with long-term care home staff, including nurses and personal support workers, is critical given their daily interactions with residents, she said.

Front-line staff members, said Dr. Moser, are often in a better position to assess the behaviour’s underlying need. Is the patient scared? Bored? Recoiling from a food they don’t like on their lunch plate?

Their familiarity with the patient, she said, allows staff to deduce “what makes that person tick while they navigate what they often see as a frightening experience.”

“This is tough work, but it has a noble goal. It’s one of the mountains worth climbing because people do better off antipsychotics than they do on them”

Dr. Moser said staff members at Baycrest were able to calm one aggressive resident after identifying a love of country music and playing it in their room. Another resident was soothed by holding a doll during periods of agitation.

She related the story of one resident who often acted aggressively. At the end of one particular shift, staff members remarked that the patient was uncharacteristically content throughout and had not exhibited a single responsive behaviour. They were puzzled; they hadn’t done anything differently that day than any other day. Then someone remembered it was his birthday and, in the morning, staff had sung “Happy Birthday” to him.

“And so, staff really ran with it — every time he became aggressive, they sang ‘Happy Birthday’ to him,” said Dr. Moser. More often than not, she said, it worked.

The hardships imposed by the pandemic — the unprecedented turnover of staff and the isolation of residents in their rooms — took away the bonding opportunities for those kinds of fortunate discoveries.

Dr. Sid Feldman, a family physician with the North York Family Health Team, and Chief of Family and Community Medicine at Baycrest Health Sciences, said moving forward together as a team with the residents’ best interests in clear focus is key to bringing down prescribing rates to pre-pandemic levels.

“This is tough work, but it has a noble goal. It’s one of the mountains worth climbing because people do better off antipsychotics than they do on them,” he said.

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