The change was the result of a cocktail of drugs, according to Pinto, that included Haldol and Seroquel — antipsychotic drugs traditionally prescribed to control symptoms such as hallucinations or delusions and the behaviors that result from them. Her father took the drug off-label — for issues not specifically recommended by Health Canada — for more than six months. He is described as engaging in “rampant exit-seeking behavior” — wandering around trying to find a way out of the house — in a medical report provided to CBC News by Pinto. However, he had never been diagnosed with psychosis, meaning that a doctor had never determined that he suffered from schizophrenia or any of the psychiatric conditions that highly sedating antipsychotics are meant to treat. Robert Pinto was just one of tens of thousands of residents in Canadian long-term care homes without a diagnosis of psychosis who were prescribed antipsychotics — a number that has been rising since the start of the pandemic, according to data from the Canadian Institute for Health Information (CIHI). ). The drug is intended to sedate and is used off-label to combat a variety of behaviors, from wandering to insomnia. “Antipsychotics are referred to as chemical restraints,” said Tamara Daly, director of York University’s Center for Aging Research and Education. These numbers had previously declined steadily. In 2019-2020, just over 20 percent of long-term care residents were taking antipsychotics off-label, a result of increased awareness about the issue that many homes were using the drugs more judiciously. But the numbers have since been on an upward trajectory. In 2020-21, 22 per cent of residents were taking antipsychotic medication without any clinical evidence of need, according to CIHI. Preliminary statistics for 2021-22 show that this trend has continued, reaching 23.9%. Those statistics are indicators of quality, Daly said. “When we see an overprescribing of antipsychotics where there is no clinical reason or disease state to prescribe them, that would be a flag,” he said. “It’s often an indicator that people in the home are being chemically treated.”
“Potentially Inappropriate”
The COVID-19 pandemic has created a number of issues for long-term care. Among them are questions about how to properly quarantine and manage people who do not or cannot understand the impact their behaviors may have on the spread of infection or the strain they are placing on an already limited resource system. But the risks of using antipsychotics are well documented. Studies have shown that they can increase the risk of falls and fractures in older adults. They have also been shown to increase the risk of strokes, heart attacks and even death. Ninety percent of those living in long-term care facilities experience some type of cognitive impairment, according to Dr. Samir Sinha, director of geriatrics at Sinai Health in Toronto. These residents have significant difficulties or are completely unable to advocate for themselves, Sinha said. “That data can be powerful enough to give them a voice,” he said. Dr. Samir Sinha is an advocate for reducing the off-label prescribing of antipsychotics. He has conducted research and participated in deprescribing efforts across Canada. (Tiffany Foxcroft/CBC) CIHI has been publishing data on “potentially inappropriate” use of antipsychotics in long-term care since 2015. The 2021-22 data was provided to CBC News ahead of schedule, according to CIHI, with the understanding that fewer homes reported due to COVID difficulties -19 and that full data quality checks have not been completed. Their latest official release, showing statistics for 2020-21, includes more than 1,300 homes spanning eight provinces and one territory. Submitting statistics to CIHI is voluntary and not every home participates, but the data includes a strong majority of facilities in the country. Statistics are missing for PEI, Quebec, Nova Scotia, Northwest Territories and Nunavut. However, many of these jurisdictions monitor the use of antipsychotics in some way. Quebec, for example, References that 40 to 60 percent of long-term care residents over age 65 are taking antipsychotics without having been diagnosed with psychosis or receiving additional doses for a reason unrelated to their diagnosis. CIHI also includes the caveat that its data captures “potentially inappropriate” cases, as some experts say there may be situations where off-label antipsychotics are warranted. “There’s obviously debate on the fringes about what the appropriate use of antipsychotics is,” said Isobel Mackenzie, who leads the Office of the Seniors Advocate in British Columbia. “It will depend on the healthcare professional you speak to and the individual situation.” Isobel Mackenzie leads the Office of the Seniors Advocate in British Columbia, which for years has far exceeded the national average for off-label antipsychotic prescribing in long-term care facilities. (Michael McArthur/CBC) Although there are questions about when and where these drugs are appropriate, there is little dispute that current levels of use are higher than they should be. “When we fund these environments to provide a certain level of care,” Sinha said. “We should expect that they should provide that level of care first, rather than taking the easy route that may actually cause more harm than good.”
Rates are rising in Alberta, Sask.
Some provinces have fared worse than others in their efforts to reduce antipsychotic drug prescribing and, in some cases, telegraphed their problems long before COVID-19 exacerbated chronic problems in the long-term care sector.
Facilities in Saskatchewan and Alberta, for example, have steadily increased their utilization rates since 2017-18.
Alberta, which for years had the lowest average usage rate in Canada, gained almost three percentage points between 2018-19 and 2020-21. For the last two years under review, he has been at odds with Ontario, a province he was previously comfortable with.
While data is not available for Saskatchewan’s 2019-20 year, it also ended 2020-21 three percentage points higher than it was just three years ago.
British Columbia has for years far exceeded the national average for long-term care and finished 2020-21 at 26%. Of the 275 clinics in BC for which CIHI has data, 90 of them provided antipsychotics without a proper diagnosis to 30 per cent or more of their patients. Nearly 20 in that group were above 40 percent, with the two highest above 60 percent.
“When we chose to focus on that, we reduced the numbers,” Mackenzie said. “But our focus — our only focus on it — shifted.”
“I don’t think anyone wants to cause harm”
There is a long list of behaviors for which a long-term care resident could be prescribed an off-label antipsychotic drug, including wandering, screaming, hoarding or even difficulty sleeping, according to Healthcare Excellence Canada (HEC), a non-profit organization. funded primarily by Health Canada. However, the HEC, which has spearheaded initiatives aimed at reducing the use of antipsychotics in some provinces, argues that the crackdown is only masking the issue. “Symptoms may appear to respond if [antipsychotic] it sedates the patient, but will return when tolerance to sedation is achieved,” states a pamphlet they developed to train medical professionals. “I don’t think anyone wants to cause harm,” Sinha said, speaking of health professionals who consider prescribing antipsychotics off-label. “But we have to appreciate that if this was your parent, is that what you would actually do, especially when that solution could cause harm?” The extra time and effort it can take to manage a person in long-term care with challenging behaviors highlights an issue for the field that has been developing for decades: changing demographics. The number of people in Canada over the age of 85 has doubled since 2001; according to Statistics Canadaand the elderly often have more complex medical needs. Twenty years ago, staff would deal with residents who had some impairments and needed a little help, Daly said. “Now, the needs are so great for each individual, and we haven’t adjusted our staff to reflect those complexities.” A general manager of a long-term care facility in New Brunswick told CBC News that when his facility opened 36 years ago, “the residents [were] coming to the nursing home by car. And, you know, now they’re coming in [an] ambulance.” WATCHES | Why are seniors overprescribed?
Seniors are overprescribed
Health workers, patient groups and governments aim to cut inappropriate prescribing for older people by 50% by 2020
The government has committed billions to long-term care
In the fall of 2020, the Liberal government committed to working with provinces and territories to create national standards of care for long-term care and provide additional support. In a statement to CBC News, Health Canada highlighted a $1 billion transfer the federal government made to provinces and territories at the time to “protect people living and working in long-term care.” They also highlighted an additional $3 billion to be made available over the next five years to “ensure long-term care standards are implemented and lasting change is made.” But the section of the 2021 budget detailing the proposed funding makes no mention of antipsychotics or overprescribing. When Laura Pinto moved her father into a long-term care home in Windsor, Ont., …
