B.C. care homes need cultural shift from 'default' use of antipsychotics, seniors' advocate says

Residents of B.C. long-term care homes are some of the most likely in the country to be given antipsychotic medications without a diagnosis of psychosis, national data shows, and experts say the discrepancy can't be explained away as a consequence of COVID-19.

Data from the Canadian Institute of Health Information (CIHI) covering 2020-21 show that 26.5 per cent of long-term care residents in B.C. were given antipsychotic drugs under "potentially inappropriate" circumstances, up from 24.7 per cent a year earlier.

That's the highest level in at least five years, according to CIHI numbers, and well above the national average of 22 per cent.

B.C. seniors' advocate Isobel Mackenzie said those numbers are in line with the information collected by her office, which shows a spike in antipsychotic use during the pandemic after years of decline.

She believes the numbers suggest many care homes increasingly turned to antipsychotics during the pandemic as visits from family were restricted and regular activities were cancelled, causing residents to become distressed.

Antipsychotic drugs are tranquilizers used to treat and prevent behaviours associated with conditions like schizophrenia, Huntington's disease and mood disorders.

While they are useful as tranquilizers, antipsychotic drugs can also cause falls and strokes, and people like Mackenzie have long expressed alarm that they're being used to subdue residents with dementia for reasons of convenience.

Though Mackenzie is starting to see therate of their use drop slightly since visitor restrictions were lifted, it's happening much slower than she would have expected.

"We've got to be very careful. There's an easy default we can fall into, which is to blame everything on whatever the crisis of the day is — so the crisis of the day is COVID, then the crisis of the day is staffing," Mackenzie said.

The real question, she argues, is why B.C.'s rates are consistently higher than in provinces like Ontario and Alberta, where CIHI data shows less than 20 per cent of residents were given "potentially inappropriate" antipsychotic medications.

"We have to take a really hard look at the culture and practice in long term care, and what it is that we're doing or not doing that we're defaulting to this prescribing of antipsychotics," Mackenzie said.

'We have not seen the investment'

The CIHI data is based on numbers voluntarily submitted by care homes, representing about 65 per cent of facilities across the country.

It's important to stress that CIHI classifies its data as "potentially inappropriate" use of the medication because it could include some appropriate off-label use, including treatment of dementia-related symptoms that trigger hallucinations and delusions.

The highest overall rate of "potentially inappropriate" use of antipsychotics in B.C. was in the Northern Health region, at 39.8 per cent, while the lowest was in Fraser Health, at 23.7 per cent.

Of the individual B.C. facilities that submitted their numbers to CIHI, some of those with the highest rates have clear explanations for why they are using these drugs, such as operating specialized mental health units.

For example, the facility with the highest rate of "potentially inappropriate" antipsychotic use, at 64.7 per cent, specifically cares for adults with "extremely complex behaviour" caused by mental health conditions, according to its CEO.

Dr. Rita McCracken, a family physician and assistant professor at the University of B.C., said it's important to recognize that when it comes to dementia, the best way to deal with behaviours like agitation, wandering and aggression is "skilled, relationship-based care," not drugs.

But she said there's simply not enough investment in research and training on alternatives to antipsychotics, including options like music therapy to soothe agitation.

"You can imagine how beautiful that interaction is, versus hiding a pill crushed up in somebody's apple sauce. They're two very, very different interventions that are very different skills and very different investments, and we have not seen the investment," McCracken said.

'A shift in the philosophy of care'

The province's public long-term care operators said they share concerns about B.C.'s high rates and are committed to reducing their use of antipsychotics.

In the Island Health region, a spokesperson said reducing inappropriate use of these drugs is now a priority and a survey was recently completed to identify facilities with the lowest rates, in order to figure out what they're doing differently.

The health authority also says it's working on a strategy that includes identifying patients receiving inappropriate medications and training staff on non-pharmacological behavioural interventions.

"This is complicated and complex work that requires multiple partners and a shift in the philosophy of care surrounding how care providers think about and approach behaviour management," the spokesperson said in a written statement.

Other health authorities said they're working on similar plans.

Ideally, McCracken would like to see a plan that includes a case-by-case intervention whenever antipsychotics are prescribed in care homes.

She recalled working in a Providence Health facility when the health authority decided to act on its unusually high rates of antibiotic use for suspected urinary tract infections in its residential beds.

McCracken said an infectious disease doctor would call the responsible physician every time an antibiotic was prescribed to discuss if the drug was really necessary — and often it wasn't.

Through those one-on-one education sessions, McCracken said, the health authority was able to drastically reduce its antibiotic prescribing rate.

"That's the kind of thinking that needs to happen around antipsychotics," she said.

"It's costly and it's not sexy, and it's going to require that we really stop and take some time to think about these people not as warehoused patients, but as unique individuals who have a very complex, terrible disease."