Got a loved one in long-term care in Waterloo region? They could be on antipsychotics without a diagnosis
When used inappropriately, antipsychotics can act as tranquilizers for seniors living in long-term care
For years, many seniors living in long-term care homes across Waterloo Region have been receiving antipsychotic medication without a diagnosis of psychosis, according to a report from the Canadian Institute for Health Information (CIHI).
The findings show that between 2020 and 2021, an average of 19.4 per cent of seniors living in long-term care homes in Ontario received antipsychotics that they may have not needed. Antipsychotic medications may sometimes be prescribed without a diagnosis to treat people with dementia (to help manage outbursts or mood fluctuations) — but that off-label treatment is not recommended by Health Canada.
"A lot of it has to do with not enough nurses to look after persons with dementia to understand why they might be expressing certain behaviours," said George Heckman, a geriatrician and the Schlegel Research Chair of Geriatric Medicine at the University of Waterloo.
"Some of it has to do with the layout of the environment. It looks like an institution and not a home, and that older person with dementia might feel distressed or ill at ease or uncomfortable, and they're trying to get out or they're trying to get somebody's attention. And rather than have enough staffing and time to figure out what's driving this, antipsychotics are prescribed," he added.
Typically, antipsychotics are used to treat schizophrenia and other disorders with paranoia or delusions. But when used inappropriately, patients will experience a number of unwanted side effects.
"There's a chemical called dopamine, and they block dopamine and they can cause people to look like they have Parkinson's disease," Heckman said.
"They can slow down your muscle function, they can cause swallowing problems. Some of them are sedating, some of them can cause falls. And there's also an increased risk of cardiovascular disease, stroke and heart attacks in people who take them for four to six weeks or more, so they're not benign medications," he added.
'Potentially inappropriate' use of antipsychotics in region
CIHI found that 22 per cent of long-term care residents in Canada are being 'potentially inappropriately' prescribed antipsychotic drugs. It is classified as 'potentially inappropriate' because the patients have no diagnosis of psychosis.
Most of the homes in the Waterloo Wellington area are either right at the provincial rate of 19.4 per cent — or lower.
But there were also some exceptions. The rate at Golden Years Long-Term Care in Cambridge was at its highest in 2020 at 41.8 per cent. That's more than double the provincial average. It was also the highest rate in all of the Waterloo Wellington area by the end of 2020.
Jenn Killing, clinical lead and vice president of peopleCare Homes, which is the parent company of Golden Years Long-Term Care, said context is key when it comes to understanding the findings.
"A high admission frequency does play a really dramatic role. Very, very high percentage of residents when admitted to long-term care from either community or hospital, are on antipsychotics without a diagnosis," she said.
"According to our current data, the average range across our three homes in the Waterloo region is 24.2 per cent... Golden Years, specifically, is currently at 22.2 per cent," she added.
She said they improved their rate by implementing a program where medical staff review the effectiveness of medications like antipsychotics.
Gradual improvement at some local LTCs
The CIHI data from previous years shows a decline in the rate from 2016 to 2020, followed by a short spike from 2020 to 2021.
Meanwhile, the percentage of seniors being given antipsychotics without a diagnosis has been trending downward at homes like Chartwell Westmount Long-Term Care. Some other homes like Chateau Gardens Long-Term Care in Elmira, also owned by Chartwell, have stayed steady under the provincial average of 19.4 per cent.
Barb Murphy, Chartwell's director of quality systems and effectiveness, said there are a few reasons why the rate may fluctuate over the years.
"When you look at some of the things that happened during that time, we had a number of residents that were admitted to the home that came with antipsychotic order that did not have a supporting diagnosis," she said. This order means health care staff have to follow a treatment directive as part of ongoing care.
"With antipsychotics, they're not something that can be just discontinued. They have to be tapered slowly. So typically, we would be waiting at least six weeks or longer to get to know the residents and to determine why the medication might have been ordered," she added.
She said gathering restrictions during the pandemic also led to a set of other challenges like not being able to meet with family and care team members. Those meetings usually help medical staff make more informed decisions about discontinuing medications for each patient.
The 'Green House' model
Heckman said any long-term care homes that want to further reduce the number of antipsychotic drugs prescribed 'potentially inappropriately' can adopt the Green House model, which has been studied by his team.
"It's a more homelike environment rather than a hallway with rooms, and the residents are engaged in the running of the household. They can help cook, they have their own separate rooms, they can walk around the ground safely," he said.
"And you know what? The data shows of antipsychotic use being much lower. They also have fewer hospitalizations. They have a better quality of life. The staff who work there have a better quality of work," he added.
He said homes using the Green House model had far lower death rates during the COVID pandemic.
He said most traditional nursing homes in Waterloo Region do not use the Green House model. Instead, they follow an institutional model that is designed to care for dozens of residents at one time.
In 2017, the union Unifor had a campaign to raise awareness that workers only had six minutes per person on average to get residents up, dressed and to the dining room for breakfast. The union said this can leave gaps in personalized care, leaving staff with very little time to do basic tasks.
Heckman said there's also a shortage of doctors who specialize in senior care working at long-term care homes. Specialized doctors can help figure out when symptoms are related to another issue or disease.
He said for instance, an elderly person experiencing a heart attack can go through phases of paranoia. Misreading the symptom and administering antipsychotics to that resident can worsen their condition.
How to protect your loved one
Jana Ray, the chief operating officer from CanAge, a group that advocates for seniors' rights across Canada, said she has heard of incidents where less-intense drugs — like anti-anxiety meds — have been potentially inappropriately prescribed.
"We've heard of a case of a family that their loved one in long-term care here [in Waterloo Region] ... [was] given lorazepam which is a known anti-anxiety medication. But he doesn't like it. He doesn't like how it makes them feel. It makes him feel very tired and sleepy and he's asked to be taken off of it," she said.
She said one of the ways you can protect your loved one from being prescribed medication when not needed is to learn what symptoms to be on the look out for.
"Drowsiness, overall sedation, dizziness, or a loss of balance are common side effects of these types of meds," she said. "At higher doses, they can result in things like confusion, disorientation, amnesia, breathing difficulties, and depression."
Ray said the best way to protect a loved one is to visit frequently to show staff at the LTC that you're paying attention and that you're there to watch over your loved one.
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