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Antipsychotics: The Art of Balance

Health Quality Ontario’s latest report examines variation in antipsychotic medication use in Ontario’s long-term care homes.

When it comes to health care, there is a great deal of variation in all aspects of clinical care. We have known this for some time and it’s an issue that exists in every health system.

Some level of variation within care is expected and appropriate. It may reflect unique patient needs and preferences or characteristics of a particular community. But there’s also variation which many call "unwarranted variation", which when observed raises questions about quality and appropriateness of care.

Variation in care should encourage us to ask questions: What does this variation tell us? Could it signal a need for improvement? What can or should be done to reduce it?

I’ve written about variation in a previous blog, Variation: A Vexing Problem in Achieving Quality, where I looked at Caesarean section rates across Ontario. Today, I am focusing on the use of antipsychotic medication use and how it varies widely across long-term care homes in Ontario. Looking for Balance, our latest report, captures the complex issues around the use of antipsychotic medications in Ontario’s long-term care homes.

These medications are used to control symptoms of psychosis or agitated and aggressive behaviours that can lead to someone hurting themselves or others. However the benefits of these drugs must be weighed against their side effects, which include a higher risk of falls, symptoms that affect quality of life (like sedation), and possibly a small increased risk of death.

We looked at hundreds of homes across the province. In some homes, no residents are prescribed antipsychotic medications; in others, however, the medications are widely used. As many as 67 percent of residents are prescribed the medications.

How could such differences between homes exist? It can partially be explained by the different types of long-term homes in Ontario. Some homes are designed for residents with severe mental illness and therefore are more likely to have much higher rates of residents taking antipsychotics. However this reason alone doesn’t account for degree of variation we see.

This issue is has been raised before in Ontario in The Toronto Star and The Globe and Mail , and in fact just recently the use of these medications was debated more broadly in a prestigious medical journal.

Underlying the wide variation, it is important to note that the overall use of antipsychotics is trending slightly downward. The percentage of long-term care residents on antipsychotics has decreased from 32 percent in 2010 to 29 percent in 2013. This decrease is statistically significant and may reflect that we are finding other ways of helping manage behaviours without the use of drugs. Some of these programs are highlighted in our report.

Looking for Balance strives to show both sides of the issue by including real stories from residents who have benefitted from antipsychotics and those who saw improvement after discontinuing their use. (You can read their stories here, or watch the video interview of one woman sharing her experience of her mother who had been prescribed an antipsychotic.) We try to accurately capture the evidence around the benefits and the risks.

As noted before wide variation should stimulate important questions. In some cases, the answers to these questions aren’t readily available – and that’s alright. It is my hope that this report will spark conversations and encourage residents, families and providers to ask questions and seek new answers together. Some of the questions might be:

  • Are people using antipsychotic medications that shouldn’t be?
  • Are patients with psychosis being prescribed these medications at the right dose? What about others for whom these drugs are not immediately indicated (such as those living with dementia)?
  • Should patients living with dementia be taking these drugs?
  • Twelve percent of residents, who had no documented diagnosis of psychosis or dementia, are using antipsychotic medications. Why are they taking them?
  • Can someone who has been on these medications for a prolonged period be re-evaluated?
  • Are there other ways to treat symptoms of agitation and aggression that are not drug-based? Furthermore, do homes have the resources and education they need to implement these alternatives?
  • When someone is prescribed these drugs in a hospital or community setting, should they be re-evaluated when they move into a long-term care home setting?
  • Are there other drugs that would be more appropriate for a given individual’s symptoms?

Residents in long-term care homes are one of the health systems most vulnerable and fragile populations, it is important that we explore these type of questions and work together to find the right balance.

I’d love to hear your thoughts on variation in health care. Please Tweet me @DrJoshuaTepper or email info@hqontario.ca.

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