30% of N.B. nursing home residents prescribed antipsychotics without psychosis during pandemic, data shows

About three in 10 New Brunswick nursing home residents were given antipsychotic medication without a diagnosis of psychosis during the early stages of the COVID-19 pandemic, according to data from the Canadian Institute for Health Information.

New Brunswick has the third-highest rate in the country of long-term care residents being prescribed these tranquillizers without a psychosis diagnosis in 2020-21, the data shows.

CIHI has deemed this "potentially inappropriate" use because the residents are given the drugs off-label, not as approved or recommended by Health Canada.

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.

In New Brunswick, the average is 30.3 per cent.

Among the jurisdictions that submitted full data sets, only the Yukon and Saskatchewan have higher rates, at 37.1 per cent and 30.5 per cent respectively.

CBC News requested a breakdown of the CIHI data by individual homes.

It shows one New Brunswick home ranks second highest in the country — Villa St-Joseph in Tracadie, at 71.4 per cent, after Alberta's Bethany Group, Rosehaven Care Centre, at 77 per cent. Rosehaven operates a provincial specialty program that cares for Alberta residents with complex needs, including mental illnesses.

Three other homes in northern New Brunswick are among the country's top seven.

Of the province's 71 licensed nursing homes, which provide more than 4,900 beds, 57 are above the national average. Six homes have at least half their residents on these drugs without a diagnosis of psychosis.

While there are some legitimate off-label uses, experts agree high rates require a closer look.

CIHI does not set a target rate, said spokesperson Angela Baker.

"Essentially, lower is better," she said in an emailed statement. "While [zero] isn't necessarily a target, it's obviously preferred that the rate of use continually declines."

Health Quality Ontario has set 19 per cent as a target rate, she said.

Eleven New Brunswick homes fall below this, with Drew Nursing Home in Sackville, the southeastern region, being the lowest at 7.3 per cent.

Nova Scotia and Manitoba results are based on partial coverage because fewer than 95 per cent of participating homes submitted data. Results for jurisdictions with partial coverage should be interpreted with caution, CIHI said.

No data is available for Prince Edward Island, Quebec, the Northwest Territories or Nunavut.

Prescribing an antipsychotic is last resort

Villa St-Joseph in Tracadie leads New Brunswick and ranks second in the country for residents on antipsychotics without a diagnosis of psychosis, but director of care Nicole Brideau said there is no inappropriate use.

"Prescribing an antipsychotic is the last thing we do," she said.

The non-profit, 74-bed home, open for 46 years, was one of 15 to participate in the first phase of the province's Appropriate Use of Antipsychotics Collaborative in 2016, she noted. The program was designed to improve dementia care by providing training to identify patients who might benefit from non-drug therapies to treat behavioural issues.

A government news release at the time said the issue was "of particular importance in New Brunswick, which has among the highest rates of antipsychotic medication use in the elderly."

"In 2013, the rate of this medication use was nearly two times higher in the province than in the rest of Canada," the news release said.

"Since that, we have been working on it and it's an ongoing process," Brideau said.

She suggested some homes might have lower scores because they're not coding patients or the reasons for antipsychotics use correctly.

"Us here, we know that we do the right thing because we were in the pilot project at first, and we had more training than the others. And I know that we are coding the patient correctly."

CIHI spokesperson Claire Brassard said all homes input their data using "standardized instruments, based on consistent training and guidelines provided by CIHI."

Any homes with anomalies should review their input practices, she said in an emailed statement.

Brideau said the year-old data doesn't reflect when individual dosages are decreased either; only whether residents are on or off antipsychotics.

She estimates 90 per cent of the Villa's new residents arrive from a hospital already taking an antipsychotic, often for more than a year. This can make the reason for the initial prescription "hard to track," and residents cannot safely be "cut cold turkey."

"We have to decrease slightly and then it takes [up to 12 weeks] weeks to decrease, decrease until we find the proper dosage or we can stop it."

The Villa usually waits about three months after admission before altering any medications to give residents a chance to settle in and get used to their new environment, she said.

It only adjusts a maximum of three residents at a time to avoid disrupting all the wings, which works out to about four residents per wing per year, she said. "So that takes time."

Quality indicator

The CIHI data is an "indicator that there might be an issue," said Colleen Maxwell, a professor and research chair at the University of Waterloo's School of Pharmacy.

But a high score doesn't necessarily indicate a quality-of-care issue, she said.

"It means that there is justification for looking more closely at it to understand why there might be variations."

There are certain symptoms, diseases and circumstances that would qualify as appropriate use of antipsychotics, said Maxwell, who specializes in pharmacoepidemiology, which looks at the use, benefits and risks of medications in large populations, with a focus on older adults in long-term care or other congregate care settings.

These clinical indications include hallucinations, delusions, schizophrenia, Huntington's chorea disease and end-of-life care.

If a resident does not have one of these and is taking an antipsychotic, they are flagged on the CIHI indicator for what's called "potentially inappropriate" use.

Most antipsychotics use is off-label, however, according to Maxwell. They are commonly used, for example, to manage behaviour in residents with dementia, such as agitation or aggression, when a medical provider determines these drugs would be useful, despite most not being medically approved for this use.

At least 62 per cent of long-term care residents in Canada had dementia, as of 2021, according to CIHI.

Risperidone is the only antipsychotic approved by Health Canada for use, short term, for aggression and psychotic symptoms, such as hallucinations or delusions, in people "with severe dementia of the Alzheimer type."

For people with dementia, clinical trials have shown the benefits of these medications in general are "modest," said Maxwell.

Meanwhile, they can pose "serious risks," she said.

Antipsychotics have been shown to increase the risk of death, stroke and other cardiovascular events, and can also lead to sedation, confusion and falls.

"So there are harms that we worry about," she said.

Pandemic sees numbers rise

Before the COVID-19 pandemic, the potentially inappropriate use of antipsychotics in nursing homes had been trending down across the country since about 2014-15, thanks in part to media attention on the issue and to new policies and programs, said Maxwell.

In 2019-20, the national average stood at 20.9 per cent, compared to the latest 22 per cent.

"It's a modest rise, but somewhat concerning," she said.

Cecile Cassista, an activist on New Brunswick seniors' issues, calls it unacceptable.

"Well, that tells me that rather than make sure that we have the appropriate staffing ratios, that they relied on heavy medication to sedate these residents," said Cassista, executive director of the Coalition for Seniors and Nursing Home Residents' Rights. "It just infuriates me."

The antipsychotics are "taking away their well-being" and quality of life, she said.

"What it's doing is finishing their life, actually. They are not themselves."

New Brunswick's pre-pandemic numbers are unavailable.

Increased stressors, fewer resources

Maxwell said it's difficult to know what's going on in New Brunswick without having data from previous years.

But she did say the pandemic might have led to more antipsychotics use in some jurisdictions.

The drugs are often used for behavioural or psychological symptoms of dementia, which can include agitation, aggression, depression and anxiety, she said.

"Some of those signs and symptoms may have increased during COVID," because of the increased stressors.

"We've seen it with other classes [of drugs] as well," she said, citing opioids and antidepressants as examples.

The pandemic has had devastating effects for both residents and staff, including staffing struggles, the barring of family members, and social isolation, Maxwell said.

And many of the first-line, non-drug approaches to managing behavioural and psychological symptoms of dementia require resources, such as time, staff, and training, that might not always be options during COVID-19, she said.

"I think for [New Brunswick] staff and for family and for residents, I think, you know, they will have questions about — is our rate higher than it should be? And should we be doing more? Should we be concerned?"

Minister 'a little surprised'

Social Development Minister Dorothy Shephard said she's "a little surprised" by the 2020-21 data, given the work the New Brunswick Association of Nursing Homes and province did several years ago to decrease antipsychotics use in nursing homes.

The province does monitor use, she said. Homes are mandated to review patient records, including medications, with the care provider every three months, for example, and this is part of their annual inspection.

Shephard also noted no antipsychotics can be used without a prescription.

"But we need to understand through their own work, you know, through their own protocols, how these drugs are being administered and utilized."

This is the first time the province has had a national benchmark to work toward, Shephard added. It will be a priority, she said.

Flagged as an issue 6 years ago

New Brunswick seniors' advocate Kelly Lamrock said the CIHI data comes with "an obligation to dig a little deeper," particularly since the province launched the program in 2016 to reduce the use of these drugs in long-term care.

"So there is already an acknowledgement that these can sometimes be overused."

The antipsychotics data can "indicate that you may — if they're overused — have situations where staff is poorly trained or under-resourced and they're making short-term decisions to buy a little peace at the long-term expense of the patient," said Lamrock.

He said his office has contacted the Department of Social Development about the data, but he declined to elaborate.

What, if any, role COVID-19 and staff shortages played in the use of antipsychotics at nursing homes in the province in 2020-21 is a question that needs to be looked into, Lamrock said.

When a particular nursing home is "wildly over" the national average, it "may suggest something beyond" a transient problem that stemmed from the pandemic, or a systemic problem, but rather "an actual problem with operation or policy in a home, he said.

"So there should be an immediate response and those questions should be immediately asked."

Alternatives to drugs sought first

At Villa St-Joseph in Tracadie, the pandemic did not affect the 2020-21 use of antipsychotics, "even though we had some periods that we were tight on staff," said Brideau.

The Villa, a Level 3 home, with residents who have either physical or mental health conditions that require assistance and supervision on a 24-hour basis, has "a lot of behaviour problems," she said, noting more than half of its residents have dementia.

Before antipsychotics are prescribed, residents with behaviour problems are evaluated and other possible drivers, such as pain, are ruled out, said Brideau.

All 75 of the Villa's health-care workers, including nurses, licensed practical nurses and personal support workers, are also trained in "gentle approach" alternatives to try, she said. That could be something as simple as changing the time or sequence of their care routines or music therapy.

The family is usually involved, but the resident is not because of their cognitive limitations, Brideau said.

If no alternatives can be found, the Villa's two doctors, who usually visit twice a week, may prescribe an antipsychotic, she said.

"I know that it doesn't settle down [aggressiveness], but we have to try to calm them a little bit so that we will be able to treat them and … to be sure [of] the security of the others too," she said. Aggressive residents sometimes push or slap other residents, said Brideau.

Antipsychotics are also sometimes prescribed to help a resident sleep, she said, because if they're overtired, they're less patient and their aggressiveness can increase.

She suspects antipsychotics use is a problem the Villa and other homes will "have to watch all the time."

Residents increasingly complex

Bruno Holmes, general manager of Manoir Edith B. Pinet nursing home in Paquetville, about 20 kilometres southwest of Caraquet, agreed.

The home has the second-highest rate of potentially inappropriate antipsychotics use in the province, and seventh-highest in Canada, at 68.5 per cent.

Residents have increasingly complex conditions, Holmes said.

When the Manoir, a Level 3 home, opened 36 years ago, residents were "coming to the nursing home with a car, and, you know, now they arrive in [an] ambulance."

More complex cases, such as dementia or Alzheimer's, mean extra work for staff, Holmes said. This has been even more pronounced during the past two years of the pandemic, with all the extra protective measures they've had to follow.

Some of the roughly 30 to 35 employees have had to go on sick leave because they're exhausted, he said.

At times, the Manoir doesn't have enough employees on the floor, or someone might have to work a double shift, but it can't post any jobs because it doesn't have any vacant positions and can't guarantee hours, Holmes said.

Still, it has not resorted to antipsychotics as a way to cope with staff shortages during the pandemic, he stressed.

"It's not the case here, for sure. I can confirm that. We almost always have a full team that's working."

During the Manoir's first three COVID-19 outbreaks, only employees were infected, according to Holmes. He did not say how many. In April, during the fourth outbreak, 28 of the 30 residents got sick, and four died.

3rd-highest home declines interview

Villa Beauséjour, an 80-bed home in Caraquet, ranked third highest for potentially inappropriate use of antipsychotics in New Brunswick and 12th highest in Canada at 66.9 per cent, according to the CIHI data.

General manager Annie Lacombe declined an interview.

"I don't want you to think that we are taking this matter lightly, but this is really not a good time," she said in an email in response to emails and voicemails from CBC about the Villa's high rates.

Home serves highest-needs francophone seniors

Les Résidences Inkerman nursing home in Gloucester County placed fourth in New Brunswick and 16th in Canada with a rate of 63.7 per cent.

General manager André Savoie attributes the high score in large part to the fact that the 30-bed facility, open since 1988, is the only French Level 4 home in the province.

The province defines Level 4 residents as having difficulties with cognition or behaviour, requiring supervision and care on a 24-hour basis. They may be aggressive toward themselves or others.

"The whole home is a special unit" for seniors with psychogeriatric needs, said Savoie.

The province's English Level 4 home, Loch Lomond Villa in Saint John, placed 65th in the province with a rate of 15.2 per cent.

Savoie admitted he finds the usage rate at Les Résidences "a little high."

"But everything is assessed regularly. And I have faith in both my doctors that are prescribing here."

Families are notified if an antipsychotic is prescribed but not before, said Savoie. 

"We're the ones that are taking care of them," he said. "And we do what's best for them all the time, like as if it was our own family member. We wouldn't prescribe anything that wasn't needed."

There is a three-day evaluation before any medication is prescribed or changed.

'Could probably do better'

Savoie thinks the home "could probably do better" on its rate but doesn't think it can be reduced even close to the provincial figure, let alone the national one.

"Our clientele is a very difficult clientele," he said, noting Les Résidences has staff assigned to do surveillance in the main lounge for safety reasons.

"We have some clients here that we can't even touch the medication because it would ... just become a nightmare," Savoie said.

"The medication was prescribed by a psychiatrist. And … they've tried so many things. And once we find something that works, we're not changing anything." 

Antipsychotics are always the last resort, he said, but sometimes are the only option.

Pandemic put antipsychotics decrease on back-burner

Foyer Notre-Dame de Saint-Léonard nursing home rounds out the province's top five for potential inappropriate use of antipsychotics, at 56.5 per cent, putting it in 41st place in Canada.

General manager Martine Lajoie said the director of care has already met with the home's prescribing doctor to discuss the rate.

Lajoie noted the home, founded by nuns in 1951 and licensed by the province since 1973, participated in phase two of the provincial program to reduce antipsychotics rates in 2017. At that time, its use of antipsychotics without a diagnosis of psychosis was at 67 per cent.

So some progress has been made, she said — even though some families wouldn't consent to their loved ones being weaned off antipsychotics because they didn't want to risk disrupting their stable condition.

"Maybe this is why our stats are higher than other nursing homes, because we started with a higher number to [begin] with, and we have a special care unit," Lajoie suggested.

Of the home's 45 beds — four of which have been kept vacant for at least a year because of a staff shortage — 20 are designated for residents with dementia or Alzheimer's.

The pandemic has made recruitment more challenging, said Lajoie.

Both the pandemic and staffing challenges may have also contributed to the higher rate of antipsychotics, she said.

"I think with the pandemic, everybody probably put the [reduction] of antipsychotics on the back-[burner]; they didn't take it as a priority, like it was just before the pandemic."

"And then with the pandemic, you have to isolate some residents in their rooms. So if they don't stay there, probably medication was prescribed also there."

Target rate not zero

Experts like Maxwell said there are cases where antipsychotics may be necessary and appropriate.

Clinicians should start with the lowest possible dose, with routine followup, and the treatment should be short term only, said Maxwell.

In addition, family members and the residents themselves should be part of the decision, she said.

While lower rates are generally better, it's difficult to say what the target rates should be, Maxwell said.

"I don't think zero is where we should be going. I think that could sort of leave some residents without an appropriate treatment, deemed appropriate for that particular case."

She suggests starting by looking at jurisdictions with rates below the national average and understanding how they got there.