Nearly half of all seniors living in a long-term care facility in Canada were prescribed antipsychotic drugs in 2014, according to a new report from the Canadian Institute for Health Information. Of those, more than 20 per cent were chronic users of the powerful medications.
The report, released Thursday, found the drugs were typically prescribed to treat symptoms of dementia, as well as schizophrenia and other forms of psychosis.
Most antipsychotic medications are not approved to treat dementia and can cause serious side effects, but they can be prescribed "off label" to treat dementia and related disorders. There are growing concerns about the overuse of antipsychotics among seniors, with critics suggesting the drugs are being used to keep individuals in long-term care facilities sedate.
"I think there is room for improvement," said Jordan Hunt, manager of pharmaceuticals at CIHI.
Mary Schulz, director of education at the Alzheimer Society of Canada, said there are cases where antipsychotic medications are warranted. But they are being relied upon far too often in seniors with dementia who live in long-term care and on their own. In many cases, other interventions are much more effective, she said.
"There are tremendous risks associated with antipsychotic use, particularly in people who are...quite frail," Schulz said.
There is a "mythology" that most people with dementia will become violent or aggressive. There are few reliable statistics, but various studies and reports suggest that 10 to 30 per cent of individuals with dementia will become violent and aggressive. Last year, a report from Ontario's chief coroner concluded there were 13 homicides in long-term care facilities in 2013 and 2014, many linked to behavioural issues stemming from dementia. The same report warns facilities against the overreliance on antipsychotic drugs and urges better training for health-care professionals and more resources to help individuals with dementia.
The system needs a "shift in culture" to address this problem, according to Schulz. Instead of simply medicating seniors, she said long-term institutions need to implement evidence-based solutions to help manage the symptoms of dementia. Schulz recalled a story told to her by an employee of a long-term care institution: on numerous occasions, an elderly man with dementia got up from his regular chair in the lounge, walked across the room and hit a woman sitting across from him over the head. Staff were preparing to put the man on medication, but decided to first investigate what could be causing this erratic behaviour. They sat in the man's regular chair and realized that at a certain time every day, the sun would shine in the man's eyes, and it appeared to come from the chair across from him. In his deteriorated mental state, he didn't realize his eyes were hurting because of the sun coming from behind the woman in the chair. He simply wanted the pain to stop, so he hit the woman he believed to be the source of the problem.
In response to the problem of aggression, violence and other behavioural issues linked to dementia, many institutions in Canada and around the world are developing "person-centred" approaches, said Schulz, which take the needs of the resident into account first. For instance, a man may get up in the middle of the night and try to leave because he worked the night shift for 30 years. Some institutions are being built to allow residents to walk and wander at will, without being a danger to themselves. Those initiatives need to be a focus going forward in order to address these issues, Schulz said.
Risperidone is the only antipsychotic drug approved to treat symptoms of dementia. However, last year, Health Canada placed new restrictions on how it can be prescribed after a safety review found the drug is linked to a heightened risk of stroke.
Now, risperidone is only permitted to be prescribed for short-term symptomatic management of aggression or psychotic symptoms in patients who have severe dementia and don't respond to other medications.
The report also notes that antipsychotics increase the risk of falls among seniors, which can lead to severe fractures and death.
A large subset of those seniors taking antipsychotics were also taking antidepressants. The report found that two-thirds of chronic antipsychotic users were also on antidepressants. And one in six residents were also taking benzodiazepines, or tranquilizing drugs, which are linked to serious side effects.
The report contained some good news. Those seniors with severe cognitive impairment and those with highly aggressive behaviour were most likely to be prescribed an antipsychotic drug. But some with severe aggression weren't given an antipsychotic, suggesting that alternative treatments were used, according to the report.