Work needs to be done to reduce antipsychotic drug rate, N.B. nursing homes association says

The head of the New Brunswick Association of Nursing Homes says having national data on the use of antipsychotic medication in long-term care homes without a diagnosis of psychosis will help lower the province's rate.

On Wednesday, CBC News reported that data from the Canadian Institute for Health Information (CIHI) shows 30.3 per cent of nursing home residents in New Brunswick were given antipsychotic drugs under "potentially inappropriate" circumstances in 2020-21.

That's the third-highest rate in the country. The national average is 22 per cent, based on data submitted by more than 1,300 nursing homes across Canada, or about 65 per cent of all homes.

"This was the first time that we saw our data compared to other provinces," association CEO Julie Weir said. "So step one is knowing where we stand, and step two is coming up with a plan to address those areas so that we can provide better care.

"So ... in talking with the homes, I said to them, 'Today is Day Zero. Now we know where we stand and we know what we need to do. So we just need to make a plan to get it done.'"

Antipsychotics are usually used to treat hallucinations, delusions, schizophrenia and Huntington's chorea disease, as well as for end-of-life care.

But these tranquilizers are also often used off-label — meaning they're not medically approved or recommended by Health Canada — to manage behaviour in residents with dementia, such as agitation or aggression. While there are some legitimate off-label uses, experts agree that the high rates require a closer look.

Cecile Cassista, executive director of the Coalition for Seniors and Nursing Home Residents' Rights, has suggested that nursing home staff shortages during the COVID-19 pandemic are behind the high rates.

But Weir contends that's "counterintuitive to what is the truth."

Drug use cut by more than half in 2016-17

In 2016, when the province launched the Appropriate Use of Antipsychotics Collaborative to reduce the use of antipsychotics in nursing homes — and residents were weaned off the drugs or their doses were decreased — staff discovered they required less care and time, Weir said.

When residents were on the drugs, they were often sleepy, less responsive and required assistance with their meals, and with being transferred between their bed and chairs, for example, she said.

After use of the drugs declined, they were more participatory in their care, she said. "We saw that very, very clearly."

During that initiative, a collaboration with the then-Canadian Foundation for Healthcare Improvement, which is now Healthcare Excellence Canada, New Brunswick nursing homes reduced the inappropriate use of antipsychotics by more than 50 per cent in 2016-17, Weir said.

This was accomplished in part by educating staff on "person-centred" approaches to care, taking into account the preferences of residents, focusing on their strengths and compensating for their losses, she said.

If, for example, a resident always slept in and never ate breakfast when they lived on their own, they might not "respond fondly" to the schedules and routines of the nursing home. So they would be accommodated as much as possible when they were admitted.

Staff were also trained on non-drug therapies, such as music, relaxation and pet therapy, to treat behavioural issues associated with dementia.

The program extended into 2018, but then funding from the Department of Social Development ended.

COVID-19 'shifted' focus

Long-term care homes "continued to do quite well" for a while, Weir said. "Then COVID happened."

Their focus "shifted" to trying to keep the virus out, making sure residents were safe and that families could visit.

COVID-19 protective measures, such as isolation, cohorting, and staff wearing personal protective equipment and "all looking alike," didn't always align with the person-centred approach.

"So we know what we need to do," Weir said. "We just need to put the focus back there and make sure that we understand that ... this is an ongoing process and that we need to go back to those same proven, tried, tested and true initiatives to look at this again."

Watch for 'unintended consequences'

Colleen Maxwell, a professor and research chair at the University of Waterloo's School of Pharmacy, agrees that having the CIHI data as benchmarks could help improve rates on the use of antipsychotics in long-term care homes.

"Data is information, and that's powerful, right? And so it is helpful ... to understand: Are regions able to do better, and how are they doing it, and can we learn from them?"

She said she believes care protocols and training could be factors.

Although reductions are positive, they can also lead to "unintended consequences," cautioned Maxwell, who specializes in pharmacoepidemiology, which looks at the use, benefits and risks of medications in large populations — with a focus on older adults who are in long-term care or other congregate care settings.

One issue to watch for is whether a jurisdiction has merely substituted antipsychotics with another medication, such as antidepressants or anticonvulsants, which also come with risks, she said.

"Without comprehensive monitoring of all these other medications and their potential appropriateness versus inappropriateness, you don't have that balanced picture."

Another issue raising concerns in some jurisdictions, such as Ontario, is so-called upcoding, Maxwell said.

"This is where a valid clinical indication for the use of [antipsychotics] is happening more frequently than seems warranted."

Ontario has seen a recent rise in some of the accepted clinical indications for antipsychotics, such as delusions, which means those residents won't be captured by the CIHI indicator because the use will be deemed appropriate, she said.

"So whether that reflects what we call upcoding or whether this is just more accurate coding of delusions as assessors — and nurses and the team get sort of more comfortable with understanding and using the tool and more accurate coding — we're not sure yet," Maxwell said.

Pilot underway

New Brunswick Social Development Minister Dorothy Shephard said the government will work with the nursing homes association to better understand what might be behind the province's antipsychotics rate and to try to reduce it.

CIHI "has now has flagged it. We've been given a national benchmark. We need to educate the primary care providers and the nursing homes, the nursing homes association as to what this means and the implications of what it looks like for their home," she said.

"As long as they're utilizing drugs properly and they can account for that, that's what we're looking for."

There's actually a pilot project currently underway that will help, Shephard said.

The Healthy Seniors pilot project, announced in April, is a $75-million federal-provincial agreement jointly led by the departments of Social Development and Health through the province's Seniors and Healthy Aging Secretariat.

A number of research projects are aimed at fostering healthy aging in New Brunswick and understanding the challenges seniors face.

This pilot will focus on developing skills on how to use data in the long-term care database, known as the integrated resident assessment instrument, or interRAI, to guide care decisions, identify safety concerns and develop quality improvement initiatives, said Rebecca Howland, spokesperson for the Social Development Department.

New Brunswick was the first jurisdiction to implement this new and improved data collection tool at licensed homes, starting in 2016-17, Shephard said.

LISTEN | High rates of antipsychotic drug prescriptions, data shows:

That's why it didn't have a national benchmark before.

It's a comprehensive, standardized system for evaluating the needs, strengths and preferences of people in chronic care and nursing home institutional settings, said CIHI spokesperson Claire Brassard.

CIHI couldn't accept New Brunswick's new data reports until its own system was upgraded in 2019, and it needed a full fiscal year of data before it could calculate the potentially inappropriate use of antipsychotics.

'We have our work to do'

There are actually 35 calculated quality indicators that will be discussed with the homes, but only nine are publicly reported, Weir said.

She said she expects the homes will meet this month to discuss the antipsychotics data with John Hirdes, a professor of health studies and gerontology at the University of Waterloo, who is cross-appointed to the department of medicine at the University of Toronto and to gerontological studies at McMaster University in Hamilton. He is also scientific director of the Homewood Research Institute in Guelph.

The pilot is scheduled to wrap up in December 2023.

"Certainly we have our work to do," Weir said.

To make a difference in the province or in the country, everybody needs to know about this, talk about it, learn about it and act on it.- Martine Lajoie, general manager, Foyer Notre-Dame de Saint-Léonard

Martine Lajoie, general manager of Foyer Notre-Dame de Saint-Léonard nursing home, which had the fifth-highest rate in the province for potential inappropriate use of antipsychotics, at 56.5 per cent, said she's hopeful.

"We still have some progress to do as a nursing home, but to really have an impact, to make a difference in the province or in the country, everybody needs to know about this, talk about it, learn about it and act on it," she said.

"This way, the more people are aware, the less inappropriate usage of antipsychotics there would be."

Weir said she's also optimistic.

"We all want to provide the best possible care," she said. "Nobody comes into this business wanting not to provide the best care to our residents."