Got a loved one in long-term care in Waterloo region? They could be on antipsychotics without a diagnosis

For years, many seniors living in long-term care homes across Waterloo Region have been receiving antipsychoticmedication 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 Ontarioreceived antipsychoticsthat theymay have not needed. Antipsychotic medications may sometimes be prescribed without a diagnosisto treat people with dementia (to help manage outbursts or mood fluctuations) but that off-label treatment is not recommended by Health Canada.

"Alot of it has to do with not enough nurses tolook after persons with dementia to understand why they might be expressing certain behaviours," saidGeorge 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, andthat older person with dementia might feel distressed or ill at ease or uncomfortable, andthey'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 forfour to six weeks or more, so they're not benign medications," he added.

'Potentially inappropriate' use of antipsychoticsin region

CIHI found that 22 per centof 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 Cambridgewasat 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 presidentof peopleCareHomes, which is the parent company of Golden Years Long-Term Care,saidcontext 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 saidthey improved their rate by implementing a program where medical staff review the effectiveness of medications like antipsychotics.

Gradual improvement at somelocalLTCs

The CIHI data from previous years shows a decline in the rate from 2016 to 2020, followedby 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 Carein 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, saidthere are afew 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 followa 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 beingable 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 saidany long-term care homesthat want to further reduce the number of antipsychotic drugs prescribed'potentially inappropriately' can adopt the Green Housemodel, 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 ofantipsychotic 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.

Small nursing homes challenge what senior care looks like

3 years ago

Duration 7:02

The COVID-19 pandemic put a spotlight on the problems in long-term care homes in many parts of Canada. With Ontario embarking on a big building project to increase the number of beds, some smaller facilities are challenging the norms of long-term care by putting an emphasis on home.

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 acampaign to raise awarenessthat 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 saidthere'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 residentcan 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 whereless-intense drugslike anti-anxiety meds have beenpotentially inappropriately prescribed.

"We've heard of a case ofa 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 medicationwhen 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 saidthe 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.