Hundreds of nursing home residents taken off anti-psychotic drugs

Hundreds of nursing home residents in New Brunswick have been weaned off anti-psychotic drugs that were found to be ineffective and the cause of increased health risks.  

"We're doing it for improved dementia care," said Julie Weir, assistant director responsible for clinical care and innovation with the New Brunswick Association of Nursing Homes.

In the last two years, nursing homes across the province have been trying to use anti-psychotic drugs more judiciously.

"We saw residents wake up and be more interactive with family members," said Weir.

"We saw residents more participatory in their care — feeding themselves, helping in transfers from bed to chair or chair to bed."

That's consistent with the experience of Daphne Stafford's mother-in-law, a resident of the Pine Grove Nursing Home in Fredericton.

She was diagnosed with Alzheimer's about 10 years ago, said Stafford.

Prior to moving into the nursing home, she had shown some aggressive behaviour, such as chasing visitors from the house, Stafford said.

Stafford doesn't know when anti-psychotic drugs were prescribed, but for a period of about a year her mother-in-law was basically asleep.

"We thought it was the disease starting to take her and we were pretty upset, pretty sad about it. But we thought it was just the progression."

As she was taken off the drug, however, the woman started to respond when her son visited and asked questions.

"She would know him … she was eating better. One of her favourite meals was burgers and fries. We even stopped and got one one time.

"I can't remember if it was her birthday or Mother's Day and she ate the whole burger by herself, which was really great, and the fries. And before that she had just been barely eating half a sandwich, if that."

Stafford's mother-in-law's condition is far from isolated.

A few years ago, one in three long-term care patients in Canada was on an anti-psychotic medication without a diagnosis requiring that class of drug, according to the Canadian Institute for Health Information.

"That's why we needed to do something different," said Weir.

Why so many are on anti-psychotics

Anti-psychotic drugs have been found helpful for patients with schizophrenia, Huntington's, delusions, hallucinations, end-of-life symptoms or severe aggression, said Weir.

But for many patients it's hard to determine exactly when and why they started taking them, she said.

"We have to assume that they were ordered appropriately," she said.

"Perhaps this individual had a fall, or a urinary tract infection or a chest infection."

Sometimes something as simple as a bladder infection can lead to delirium or psychosis in an elderly person, according to registered nurse Monique Comeau.

"It's ordered for a specific behaviour and can have some effect,"  Weir said.

But evidence shows the effect lasts only for about six months, she said, and after that the medication doesn't change behaviour.

"Two, three, four, five years later, we need to ask, "Are these meds still appropriate? Are they helping? Does my loved one still require this class of drug?"

Weir said those questions have now become part of the culture at nursing homes provincewide.

During the period of the study in 2016 and 2017, data was collected on 580 individuals who did not have a diagnosis to support being on an anti-psychotic drug, she said.

Their care teams monitored them as their prescriptions were decreased and 52 per cent of the patients ended up on a lower dose or off the drug entirely.

Many more residents have been de-prescribed since then, said Weir.

The effects have been beneficial to patients and nursing homes, she said.

"Nobody wants to over-sedate their residents. We all know over-sedated residents are more care. 

"When somebody is on anti-psychotics long term, we know the risks — heart attack, stroke, falls, swallowing difficulties — are through the roof."

Dealing with responsive behaviours

Comeau, who works at the Pine Grove home said she's always been inclined to think there's a better way of dealing with "responsive behaviours."

That's the new term the home uses for "aggressive" behaviour.

"The resident is responding to an external or internal stimuli like fear or pain," Comeau said. "They're not being aggressive for being aggressive.

"We tend to go into a rut of prescribing medication and the behaviour seems to go a way for a little while. And then it returns. And then you give more medication and it goes away for a little bit and comes back. So obviously this was not working."

Comeau said staff now have new approaches to dealing with the emotional impact of dementia, such as finding key words to encourage a resident to do something, being slow and gentle and giving the resident time to process information, and giving themselves permission to walk away until the resident is in a more receptive frame of mind.

Comeau said "responsive behaviour incidents" are actually down, and so are staff injuries.

"Everybody wants to do the very best for the residents."

"A diagnosis of dementia or Alzheimer's is not a psychiatric illness."

The national statistics, according to the Canadian Institute for Health Information, have come down a bit too. The most recent figures indicated one in five long-term care residents were on an anti-psychotic drug without a diagnosis requiring it.