Chemical Restraint

Seniors in Ont. nursing homes overprescribed antipsychotic drugs: study

In the nursing homes with the highest antipsychotic prescribing rates, 16.6 per cent of patients with neither psychosis nor dementia were given the drugs, according to a recent study.

Ontario nursing homes are too quick to give vulnerable seniors antipsychotic drugs to keep them calm, suggests a disturbing new study examining prescribing rates for the drugs at 485 facilities.

The study of 47,322 residents in provincially regulated nursing homes indicates the average rate of antipsychotic prescribing by home ranged from 21 per cent in the groups with the lowest average rate to 44 per cent in the highest category.

Residents in nursing homes with high prescribing rates were three times more likely to be given antipsychotic drugs – whether they need them – than others in facilities with lower antipsychotic prescribing rates, indicates the research by the Institute for Clinical Evaluative Sciences.

“These results suggest antipsychotic therapy is not being prescribed based on their clinical indication,” the researchers write in the latest issue of the Archives of Internal Medicine.

“Rather, the decision to prescribe an antipsychotic therapy appears to be related to the nursing home environment, with some environments being more permissive about antipsychotic use.”

The research also indicates among the 8,058 residents who had no condition requiring antipsychotic drugs, 10.4 per cent or 839 were nonetheless medicated. In the nursing homes with the highest antipsychotic prescribing rates, 16.6 per cent of patients with neither psychosis nor dementia were given the drugs.

“Prescribing antipsychotic therapy to a resident with no clinical indication for the therapy has been identified as a measure of poor quality of care,” the study says.

Lead researcher Dr. Paula Rochon said antipsychotic drugs have side-effects including sedation, higher risks of falls and hip fractures and Parkinson’s disease-type symptoms.

“Sometimes people are using them for the wrong reasons,” Rochon said in an interview. “These are drugs that should be reserved for situations where the benefits outweigh the risks. They certainly are not drugs that should be used to deal with sleep problems or people wandering.”

Rochon, a geriatrician, said that before drugs are prescribed, greater effort is required to address the reasons for residents’ agitation.

Researchers in another study, for instance, found antipsychotic therapy was reduced by 19 per cent following the introduction of training and support programs focusing on alternatives to drug use for the management of agitated behaviour.

“Initiatives such as this provide an important alternative to antipsychotic therapy and should be used more uniformly across nursing homes.”

Rochon said concerns about high rates of use of an earlier generation of antipsychotic drugs prompted legislators in the United States to pass a law governing their use in nursing homes. Following the introduction of the 1990 legislation, use of those drugs fell to 17 per cent from 24 per cent with no documented evidence of detrimental effects to residents.

Since then, new generations of antipsychotic drugs have been introduced and are being used more and more often, although it is now becoming clear there are serious safety concerns associated with them as well.

Rochon stopped short of saying Ontario should introduce legislation dictating when nursing home residents should be prescribed antipsychotic drugs, but observed the rate of use of such drugs should be monitored by provincial regulators as one of the indicators of quality of care.

Karen Sullivan, executive director of the Ontario Long-Term Care Association, said the variation in prescription rates for antipsychotic drugs has more to do with attending physicians than with nursing homes themselves.

“Every home pays a physician outside of the (Ontario Health Insurance Plan) OHIP-funded services to be their medical director and then residents all have attending physicians who are their primary care physician who prescribes their medication.”

Sullivan, whose association represents more than 400 profit and not-for-profit nursing homes, noted the researchers based their study on 2003 data and suggested the situation has improved since then because the province is now paying doctors more so they’ll spend more time with long-term care patients to better understand their needs.