Alberta sees rise in potentially inappropriate antipsychotic use in long-term care

Potentially inappropriate antipsychotic drug use in Alberta long-term care homes rose during the COVID-19 pandemic, new data shows. 

During the 2021-22 fiscal year, 23.9 per cent of long-term care home residents across Canada were given antipsychotic drugs in a manner deemed potentially inappropriate, according to new preliminary data from the Canadian Institute for Health Information (CIHI). The data was provided to CBC News on Tuesday. 

Alberta sat below the national average with a rate of 21.9 per cent.

CIHI's definition of "potentially inappropriate" means an individual does not have a diagnosis of psychosis that would justify the use of antipsychotics. 

The Alberta numbers are an increase from CIHI's data for the 2020-2021 fiscal year, which showed the province at 19.9 per cent.

CIHI said the latest provisional data should be interpreted with caution, noting not as many homes reported due to the pandemic and the data is yet to go through their final adjustment and vetting process. However, the data confirms a spike in the potentially inappropriate use of antipsychotics in long-term care, an issue that has concerned experts for years.

Usually, antipsychotic drugs treat conditions like schizophrenia, Huntington's disease and dementia-related delusions. They have also shown benefits in end-of-life care. 

But antipsychotics are often used "off-label" — that is, in a way not specifically recommended by Health Canada — and in some circumstances are used as a chemical restraint. Of this class of drugs, only risperidone is approved by Health Canada to treat some symptoms of dementia.

Residents in long-term care may be prescribed antipsychotics to treat agitation, aggression, screaming or pacing, despite experts across the country pointing to a lack of evidence showing the medications are effective in managing these behaviours.

Instead, many geriatricians working in long-term care suggest interventions like music therapy, pet therapy or changing environmental factors. Studies have shown these can help mitigate the behaviours.

Experts say the drugs can come with negative side effects.

"It could affect the person's ability to walk safely. It could lead to falls and fractures," said Dr. David Hogan, a geriatrician and professor of medicine at the University of Calgary. 

"These drugs are associated with a small but definite increase in mortality over the short term. So you really don't want to use these drugs until you've exhausted other opportunities."

Alberta guidelines

Within Alberta, Edmonton Zone has consistently ranked among the top 10 per cent of jurisdictions across the country for its low rate of inappropriate use of antipsychotics. 

Experts attribute the province's success to a project taken up by Alberta Health Services in 2013, which resulted in the development of provincial guidelines and resources for the Appropriate Use of Antipsychotics (AUA) initiative. The initiative provides families and long-term care workers resources to evaluate options before prescribing antipsychotics. 

In a statement, AHS said that 86 per cent of families interviewed reported increased alertness, improved communication and more happiness for their loved ones after antipsychotics were tapered or discontinued.

Over the past five years, AHS said, it has received eight complaints related to the use of antipsychotic medications in long-term care, supportive living or home care environments.

"The good thing is that overall provincially, we've been reducing the use of antipsychotics over time," said Charlene McBrien-Morrison, CEO of the Health Quality Council of Alberta.

The council collects data on antipsychotic use in the province.

McBrien-Morrison said that before the initiative took place Alberta in 2011, 27 per cent of those in long term care were classed as receiving antipsychotics potentially inappropriately. After the project was completed,  that number had dropped to 21 per cent. That number lowered even further to 17 per cent in 2018.

The latest numbers follow a slow upward trend — 18.1 per cent in 2019, 19.9 per cent in 2020 and 21.9 per cent noted in preliminary data for 2021.

Numbers vary across the province

The numbers also vary across the province. They are lower in urban zones like Edmonton and Calgary. The Central Zone health region, which includes Camrose and Wetaskiwin, tracked the highest rate. 

"There is considerable variation across nursing homes, but largely that can be explained by the very differing types of older residents who are in each home," said Dr. Adrian Wagg, a professor of healthy aging at the University of Alberta who worked on the AUA toolkit. 

Other potential factors can influence the rate in zones across the province but exact reasons for the regional variations exist have yet to be explored, said Wagg.

Wagg said evidence from the U.S. suggests that private institutions may not take on residents with more complicated needs, leaving them to publicly run facilities like hospitals and health-care centres.

"Hospitals and health-care centres may be less conducive environments for the care of these people in terms of environmental and institutional factors," Wagg said. 

There are also homes that care specifically for those with behavioural responses that are not able to be managed in a traditional long-term care setting. 

Facilities that specialize in complex care tend to report higher rates of antipsychotic use.

For example, of the three care homes Shepherd's Care Foundation operates in Edmonton, its Eden House home for complex needs had a rate of 39 per cent, while its other homes in Millwoods and Kensington fell below the provincial average at 13 and nine per cent respectively. 

The Bethany Group operates three of the facilities which rank the highest provincially, all located in Central Zone, including the Rosehaven Care Centre in Camrose, Alta., about 100 kilometres southeast of Edmonton.

Rosehaven offers a provincial specialty program that cares for residents with complex needs including mental illnesses. CIHI data shows Rosehaven's rate of potentially inappropriate antipsychotic use in 2020 as 77 per cent. 

Bethany Group CEO Carla Beck attributes the high rate to a combination of factors, including key differences in its resident demographic from most long-term care homes. 

"We know that we have difficulty in discharging residents from Rosehaven to other long-term care sites that aren't our own and what we're told is that those sites do not want to accept clients who require antipsychotic medications."

While experts agree lower rates are better, there are circumstances where antipsychotics may be necessary on a case by case basis. 

Hogan said it is important for clinicians to prescribe the lowest effective dose for the shortest duration of time, and then review and evaluate to determine whether people can be taken off the antipsychotic medications. 

"The right rate wouldn't be zero," he said, "but the right rate is probably lower than 20 to 22 per cent."