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5. Antipsychotics, Elderly & Long-Term Care with Laura Hill

Updated: Jul 31, 2022

Our podcast today looks at the use of antipsychotic medication with elderly people my guest is a co-researcher. Together we looked at the use of antipsychotic medication with people in long-term care in Ontario. It's important research and there needs to be more and more and a lot of dissemination because the use of antipsychotic medication with the elderly has huge risks and there are alternatives in many cases.

This research is one of several research articles that have been published in the Nurse Practitioner Open Journal. Remember that the Nurse Practitioner Open Journal is fully accessible online and it's free for authors to publish. In fact, we've just published our second issue! Don't forget to check it out at

Hello everybody and welcome to our podcast, today we have Laura Hill. She's one of my colleagues and we've done some research together.

Today we're going to talk about a research project that we did, and published in the nurse practitioner open journal called, Nurse Practitioners and the use of Antipsychotic Medications in Long Term Care in Ontario, Canada.

Welcome Laura would you start by telling us a bit about yourself.

Sure. I've been a nurse practitioner since 2013 graduating from the adult program at University of Toronto. I worked for the first three years as a nurse practitioner in the emergency room here in Sudbury, and then went on maternity leave and came back to a new job in a Geriatric Outpatient Clinic where I do a blend of medical care, had like an internal

medicine consult for geriatrics, but then also geriatric rehab programming.

Well, given that background, I'm sure that you are well versed in our topic of the day which is at psychotics with the elderly. Can you give us a bit more of why this topic was salient with what you were doing?

Yeah, for sure. So one of the main things that we do get referrals from urgently when we're trying to see patients in an urgent basis in community is the behaviours and of dementia.

And there's a general lack of understanding, I think in community providers about how to help family members who are living with a person or trying to care for a person in their homes or have a behaviours in relation to dementia, and it's about 80% of people with dementia that will end up with these behaviours so it's a huge issue, we have so many people living with dementia.

And when they are at a loss they often just throw an antipsychotic at it, in hopes I think that it will stick and calm some of the behaviours down, but there's a lot of risks with it too.

And so I wanted to highlight that.

So this was something that you were seeing in your day-to-day practice. It was also something that I was interested and it led us to do this reserach. So let's take a little bit of a look now at the background of antipsychotic medications. They were developed for use for mental health issues, particularly for people with psychosis andin the treatment of schizophrenia. There are first and second generation antipsychotics and in Canada risperidone is the only antipsychotic that is approved for the treatment of severe behavioural and psychological symptoms of dementia. Those are the types of behaviours that create a lot of difficulty for caregivers, the kind of behaviours that move the caregivers to seek treatment, which may lead to antipsychotic use.

The American Geriatric Society's Beers Criteria recommend that only after all non-pharmacological options have failed and only if the patient is a significant harm to self or others should antipsychotic medication to be considered for the BPSD, or those behavioural symptoms.

There are a lot of reasons for concern with antipsychotics in the older adult population. They increase the risk of stroke, a decline in cognition and increased mortality. So, they're not benign medications.

At the same time there aren't a lot of quick and easy options for the treatment of these difficult behavioural symptoms that some people with dementia portray. The result is that several studies have shown that residents in long-term care facilities, in particular, have been prescribed antipsychotics for potentially inappropriate reasons, one being to manage the behavioural symptoms.

We thought this research might be of interest to nurse practitioners because NPs are becoming more and more prevalent in long-term care. At the same time the literature shows that the use of antipsychotics with the elderly is an issue not only in Ontario where this research was completed but across Canada and North America and potentially farther.

Most of the research today also addresses physician prescribers and since NPs are becoming more common in long-term care highlighting this research to them is important. That's why we thought it was important to published in the Nurse Practitioner Open Journal.

You know, and together we had the opportunity to get a very, very large and comprehensive data set. In Ontario, long-term care facilities collect data on residents every three months using the Minimum Data Set. This is an assessment that includes questions about demographics, such as the age and sex of the resident and also variables about the levels of their functioning, which is things like their ability to walk and dress and eat and toilet independently, or with assistance and accesses also their behaviors like crying and lashing out and withdrawing.

It includes medical diagnoses and categories of medications that the resident has been given in the last seven days, or treatments such as physiotherapy and there are even some variables about the residents, overall condition or changes in their conditions such as a flare of an acute condition or deterioration in their overall status and their end stage of life. So, you can you can probably see that we would get a huge amount of information because we received a data set of all of these assessments that were completed over a full year.

And since residents have assessment every three months, we ended up with 372,469 assessments. We used the final assessment, or the most recent assessment on the resident and that left us with 101,315 cases. So ,what we did was analyzed whether the resident had been given an antipsychotic medication within the past seven days. And we analyzed those who had received antipsychotic medications versus those who have not. So, we looked at the variables associated with antipsychotic use.

All right, well the findings were unfortunately not that surprising. Of the sample, 32% had received an antipsychotic in the past seven days. There was an increased likelihood of antipsychotic use for women, for those with a diagnosis of schizophrenia, which is not unusual for those who exhibited pain and for those who are self-deprecating. There was a significant likelihood of antipsychotic use when any of the behaviours found in BPSD were identified, such as resisting care disruptive physically abusive verbally abusive and wandering. So, we had to sort through all this and what your thoughts about some of these findings?

Well my initial thought was that it's even though it's Long-Term Care residents it's very similar to what we're seeing in community is that these are the behaviours that are disruptive to the people trying to keep them well, or trying to keep them safe, and that when we put that into a long-term care perspective it's no longer people who are taking care of them out of love, or out of duty, because their family members, it's people that we're paying very little and we don't staff well enough. And it really struck me that the things that seem to trigger a use of antipsychotic would be the things that, when I'm taking students into a long-term care facility to have them sort of work as a PSW in their very first placement. Those are the things that make their job way harder. So, if someone's resisting care, that means that they're taking way longer than their allocated two minutes to toilet them, or to get them into the shower facility or to get them dressed and up and ready for their meal in the mornings. And so I found it to be shocking that we would probably be over using medications with such serious side effects in order to keep our staffing levels as minimal as they are, so that people can continue to make money off the backs of our elderly population. That's a whole other thing but I get very frustrated with a for profit situation that our elders, find themselves in.

Yes, it does seem like staffing has a huge impact on the amount of care that people can be provided when they are exhibiting disruptive behaviours. It doesn't seem to be surprising then that that group of patients is significantly more likely to receive an antipsychotic.

For sure, and you think about if you were a personal support worker trying to get 20 people up and ready for the day and three of them are causing you grief, because they have these disruptive behaviours, you're probably going to go to your charge nurse or your staff nurse and saying "Hey, like we got to do something about the guy in 18, he's really, you know, making life difficult I can't get him up, you won't leave dentures in. I haven't been able to change his brief, so I didn't get him up" They've got standards that they have to follow.

And so, those constant, you know, going to your staff nurse to pass on this information that there's something going on, isn't really being addressed probably with a non- pharmacological, which should be our first one right we should be trying to figure out why the behaviours exist in the first place. Using all of our non-pharmacological interventions first, and using them only as a last resort.

And you know, even though the data don't provide contextual information. Some of these conclusions or assumptions that we are making arise from previous studies that were done in Canada related to long term care. One in particular that I thought was really interesting was that it was a cluster randomized control trial that demonstrated that daily treatment of pain significantly reduced agitation and long -term care residents with moderate, or severe dementia. And the strategy has the potential to reduce the number of antipsychotic prescriptions is Husebo et al 2011, and I'll put the full reference in the notes, online, and the transcript. But it's, it's things like that that you see and you wonder how

consistently people are able to implement some of the non-pharmacological trials, or to try something completely different to support patients, or residents when they're experiencing those symptoms.

Yeah, I guess, saying non pharmacological I should be probably more clear just a non- antipsychotic pharmacological So, because sometimes we do need pharmacological, right? So if it's pain related they certainly should be getting a pharmacological treatment for that, that can be as simple as just having Tylenol available on a regular routine basis and not as needed, because as their dementia progresses, or if there's a language barrier, they

may not be able to tell you that they're having pain in the first place. And that gets frustrating when you're the person living with pain, and no one understands what you need.

And then the other thing too that's often untreated with dementia is their co-morbid depression and anxiety, and those again can do well with pharmacological treatments. But it doesn't have to be an antipsychotic. People who are experiencing memory loss are sometimes aware that they're experiencing that memory loss, and they're aware that they're not living in their own home with their people anymore. And it's so distressing and you can imagine that they are very much experiencing depression, and they have very little control over their life. So if they have any pre-existing anxieties, it's just made worse in a situation where they can't even control at what time they have breakfast

...or how late they get to sleep in. That would be a problem for some people in my life! So in our article we discussed a few of the actually non pharmacological approaches such as Gentle Persuasive Approach and P.I.E.C.E.S. What do you see are the challenges with those?

They're time intensive and that again comes down to the staffing. To go through P.I.E.C.E.S. you're trying to actually sort out what makes that person. You're trying to sort out what were their personalities, what did they like, what were their interests, who is their family what brings them comfort? You're trying to go through, basically, their whole life history, truly know the person, and then know what interventions, but then work with that person. So it's not a one size fit all. We talk about giving people baby dolls sometimes in the long-term care facilities, and that doesn't work for everybody that does work for a population of people who really valued, you know their children and their grandchildren. Sometimes when dementia has taken over, giving them dolls gives them comfort. But that doesn't work for everybody, nor does giving somebody the job to pass out water. That works great on old nurses who just want to help, but it doesn't work on people who don't want to do that. So, getting to know them but it takes a lot of time you really, and you have to you know track down family who knows them because they may not be able to tell you what really was valuable to them.

But then do those implementations take time. It's not just as simple as like getting them to go fill up the glasses of water you probably have to go filled up the water for them, and then have them pass it out. They may not be able to initiate the actual chore.

And at the same time to put things in perspective, can you talk a little bit about the six-minute challenge?

Yeah, so that was a social media hashtag that went a bit viral for a while. And it was people trying to demonstrate that you can do very little to get yourself ready for the day in six minutes and that is the time that personal support workers are given each day per resident, to get them and ready for the day. That includes dressing, dentures mouth care, toileting. You know they need to have their and continent product changed, if they need to have a wheelchair brought in, with a Hoyer life, getting a second person into now help you get the person into the Hoyer lift. So in six minutes, the personal support workers who are working in these challenging environments did joking videos but tried to show you know "my hair is only half washed, I didn't get the conditioner out, my makeup only on one eye, I have only my pants on today" just to really bring to light that six minutes is so not enough. And that's all you have per resident. There's no way you're going to get them to do anything. They're not speedy. They've got lots of reasons to not be fast, and we can't even get, you know, teenagers dressed in six minutes and out the door.

In all of this I mean we certainly see there is a problem, the antipsychotics are still being prescribed potentially inappropriately it does appear to be so. That there are huge issues with the ability to provide the care that people need in order to address some of the behavioural problems that arise with dementia. So, what do you see as the nurse practitioner's role in this and long- term care?

Yes, I think that's, it's a role that we can really capitalize on, and there's hope that this will happen. But the big difference will be is that they can be more available, and more present with the residents with the staff with the families, whereas our current general system, not every home is the same, but our current situation is that physicians are often only

in once a month. They may only be available by phone. They may not know the residents as intimately as they would potentially know their own family care patients. You know the community where they've known you for 20 years and they've seen you grow and they've added the medication for themselves. They are at a disadvantage where they're getting a person brought in who they haven't had a chance to know and grow with.

And they never really get a chance to develop that relationship because the way that we structured the system. But a nurse practitioner who was assigned you know whether it's you know one or two or four homes even, but that's their only job, they can make a huge difference because they'll be there to get to know the staff. Staff then trust them to know and to teach and to lead them into a new, better way of caring for our elders in our communities.

And I think there is some research already that shows that nurse practitioner presence in long -term care does make a difference in the quality of care that the patients are receiving so this could be, there's potentially for this to be another piece of that.

I think it's a win, not just for issues of dementia but it's going to be a win for all sorts of different things but even just noticing what a patient's not doing as well as they've had been doing the week prior, you'll notice those acute and chronic changes if you're with them more frequently, hands on and face to face with the person.

So of course, any research, always has its limitations and other limitations with this is that the MDS. data set is, we were saying doesn't have contextual data, data also doesn't tell which medication was prescribed and whether it was short term or long

term. So, when it comes to anti psychotics we aren't entirely sure it does lay the groundwork for future research though, and particularly research that involves nurse practitioners in long term care.

Is there anything else you want to add about this research?

I think that, as you said, it leads to further research, and I think that the more in depth and you know the true information that we can gather about the medications that are being used on which patients but which behaviours, and then hoping to find the places that we can make small wins will be great, so that is pain like we know this is one that is often targeted. If we targeted with actual pain medication though can reduce the impacts of antipsychotics, which have huge side effect profiles and actually cause more harm with the falls and the chances of Parkinson - like symptoms and interactions with other medications when we can just target the actual issue.

I think that that future research will be so vital into increasing our respectful care of our elderly patients. It's frustrating to know that you've worked your whole life and you know done so much potentially for community and then when you truly need a lot more care, it's just not really there for us anymore. We've lost the fact that these are not factories for old people.

And it becomes more alarming as you inch closer to those years. All right, Laura. Thank you very much. This has been great.

Thank you!

Husebo, B. S., Ballard, C., Sandvik, R., Nilsen, O. B., & Aarsland, D. (2011). Efficacy of

treating pain to reduce behavioural disturbances in residents of nursing homes with

dementia: Cluster randomised clinical trial. BMJ, 343(jul15 1), d4065–d4065.

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