The risk of using antipsychotic medications to treat dementia

Background

In addition to cognitive impairment, people living with dementia may experience changes in mood and behaviour, such as:

• Aggression,
• Delusions,
• Hallucinations,
• Agitation,
• Wandering,
• Apathy and
• Mood disorders (in some cases).

These symptoms can appear, change or worsen as the disease progresses.

While antipsychotic medications are typically prescribed to manage psychotic conditions such as schizophrenia and bipolar disorder, they are also used to treat psychological and behavioural symptoms in people with dementia.

Often, they are administered in long-term care homes, where people living with dementia have advanced symptoms and require 24-hour care.

What are the issues?

Over-prescription

In Canada, about one third or 30.2% of residents in long-term care are prescribed antipsychotic medications.

This is contrary to criteria set out in the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication use in Older Adults.

According to this criteria, antipsychotic medications should only be used by people living with dementia if:

• Their behavioural problems do not improve with non-drug approaches;
• The person is threatening to harm themselves or others; and
• They are not used for more than six to 12 weeks.

Uneven usage

The use of antipsychotic medications in Canada also varies considerably from province to province and from one long-term care home to another.

This is despite the fact that there are very few differences between residents in one long-term care home versus another, or in one province versus another.

In Ontario, for example, long-term care residents are three times more likely than similar residents to receive an antipsychotic drug if they live in a long-term care home with high prescribing rates, instead of a long-term care home with low prescribing rates.

Risk

As the human body ages, it reacts to medications differently. This puts older adults at an increased risk of adverse events from medications.

In particular, antipsychotic drugs have been linked to an increased risk of falls, diabetes and heart disease. Older adults are also more likely to be prescribed multiple medications, increasing the likelihood of negative drug interactions.

Higher rates of hospital admission or death have also been reported after the short-term use of antipsychotics in older adults, suggesting that these drugs should be prescribed with extreme caution.

Our position

The Alzheimer Society recommends that antipsychotics only be used as a last resort to treat behavioural and psychological symptoms of dementia, especially in older adults.

The Society encourages health professionals in all settings to practice a person-centred approach to care for people living with dementia:

• When staff take the time to understand each individual as a unique human being with specific needs, preferences and values, they are better able to recognize their behaviours, remove triggers that may be at the root of the behaviour and provide more personalized care.
• When put into practice, this approach can reduce and even eliminate the use of antipsychotics.

In cases where these drugs must be prescribed, the Alzheimer Society recommends that:

• Staff, family members and the person living with dementia be informed of the risks, benefits and side effects.
• The taking of these drugs should be monitored regularly and discontinued immediately if adverse effects occur.
• Recommended practice guidelines should be followed to assess the efficacy of any antipsychotic medications and to cease their use if no obvious benefit for the person is noted.

The Society also urges that more training and education be provided for healthcare workers on dementia-specific care practices and person-centred care. With increased skills and knowledge, staff can deliver better quality of care that all people living with dementia need and rightly deserve

More useful links and resources

Use of antipsychotic medications to treat people with dementia in long-term care homes. Alzheimer Society of Canada, 2017. Our full position statement on this topic.

Providing person-centred care. Alzheimer Society of Canada. Person-centred care is a way of thinking that recognizes that individuals have unique values, personal history and personality and that each person has an equal right to dignity, respect, and to participate fully in their environment. On this page, healthcare providers can find out how they can apply person-centred care to their own practices.

American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society, 2015. This paper lists potentially inappropriate medications to be avoided in older adults, including those who are living with dementia. Note that the full text is behind a paywall.

Anti-psychotics in older adults. brainXchange, 2015. This presentation describes antipsychotic drug therapies and their use in older adults, and discusses alternative management strategies. Presented by Dr. Paula Rochon, MD, MPH, FRCPC, Senior Scientist with the Women’s College Research Institute and Vice-President of Research at the Women’s College Hospital. In partnership with the Canadian Consortium on Neurodegeneration in Aging (CCNA) and the Alzheimer Society of Canada.

Antipsychotic therapy and short-term serious events in older adults with dementia. Paula A. Rochon, MD, MPH, FRCPC; Sharon-Lise Normand, PhD; Tara Gomes, MHSc; et al, 2008. This investigation found that serious events, such as hospital admission or death, are frequent following the short-term use of antipsychotic drugs in older adults living with dementia. A downloadable PDF of the full paper is available.

Appropriate use of antipsychotics. Canadian Foundation for Healthcare Improvement (CFHI). CFHI works with Canadian long-term care organizations to set standards on the appropriate use of antipsychotics to treat people living with dementia in long-term care homes across the country.

Drugs used to relieve behavioural and psychological symptoms in dementia. Alzheimer's Society UK. This webpage gives an overview of drug treatments to treat behavioural and psychological symptoms in people living with dementia, while also emphasizing non-drug approaches.

Effects of person-centered care on residents and staff in aged-care facilities: a systematic review. Sonya Brownie and Susan Nancarrow, 2013. This paper looked at long-term care homes that shifted to person-centred care, and the resulting effects for both the residents and the homes' healthcare providers. The full text of this paper is available to read online.

Looking for balance: Antipsychotic medication use in Ontario long-term care homes. Health Quality Ontario, 2015. This report sheds further light on antipsychotic medication use in Ontario's long-term care homes.

Potentially inappropriate use of antipsychotics in long-term care. Canadian Institute for Health Information (CIHI), 2018. CIHI provides some helpful statistics on how many long-term care residents in Canada are taking antipsychotic drugs without a diagnosis of psychosis.

Treating behavioural problems of dementia: When confusion leads to controversy. McMaster University, 2014. This blog advises that treatments for behavioural problems in people living with dementia should always include appropriate assessment and diagnosis, followed by non-drug treatments such as environmental or behavioural interventions. Authored by Dr. Nathan Herrmann, Professor of Psychiatry in the Faculty of Medicine at the University of Toronto and Head of the Division of Geriatric Psychiatry at Sunnybrook Health Sciences Centre.

Variation in nursing home antipsychotic prescribing rates. Paula A. Rochon, MD, MPH; Therese A. Stukel, PhD; Susan E. Bronskill, PhD; et al., 2007. This study examined excessive prescribing of antipsychotic therapy in long-term care homes in Ontario. A downloadable PDF of the full paper is available.