Inappropriate use of antipsychotics

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For residents of Ontario’s long-term care homes, antipsychotic medications may play an important role in managing the behavioural symptoms that sometimes occur with psychosis or dementia, such as agitation and aggression. But the use of these medications has sparked controversy across the province, the country and around the world because of side effects such as sedation, higher risk of falls and slightly increased risk of death. Family members of long-term care home residents may also see their loved ones struggling to communicate or sleeping for large parts of the day as a result of antipsychotic medication use. Without the drugs, however, some residents and their families might suffer because of behaviours that put them or others at risk.

Change Ideas

Identify improvement efforts planned or underway, including what resources and supports are available

Review the quality standard Behavioural Symptoms of Dementia
Ontario Health Quality Standards
Explore opportunities to work with the home’s behavioural response team and champions
Consult with external teams, such as psychogeriatric resource consultants, Behavioural Supports Ontario, and seniors’ mental health services

Verify current resident data

Review the data from your home and pharmacy provider (indications, new starts, summary of responsive behaviours, interventions)
Sign up for long-term care practice reports for data and change ideas to reduce prescribing for antipsychotic drugs
MyPractice: Long-Term Care
Verify the data on the number of residents prescribed antipsychotics, including new starts, prns, and administration rates
Request a medication-tracking tool from your pharmacist

Improve medication review process

Consider a team approach to quarterly medication reviews, involving physicians, pharmacists, and nurses
Use a standardized and simplified medication review process (see sample worksheet from Alberta Health Services)
Pharmacologic Restraint Management Worksheet
Review the continuous use indicator at quarterly multidisciplinary medication reviews and summaries of resident recent behaviours, and identify residents who may benefit from trialing an adjusted antipsychotic use/dose

Update and implement individualized behaviour care plans

Use standardized assessment tools to inform care plans (e.g., DOS, CMAI, KSBA)
Behavioural Supports Ontario – Dementia Observation System (BSO-DOS©)
Kingston Standardized Behavioural Assessment
Rule out triggers of adverse behaviour, such as pain, constipation, infection, or medication issues. Use the P.I.E.C.E.S. assessment tool
P.I.E.C.E.S. - A practical, effective approach to change and continuous improvement
Trial nonpharmacological strategies before antipsychotic medications, where appropriate
Centre for Effective Practice: Use of antipsychotics in Behavioral and Psychological Symptoms of Dementia (BPSD) Discussion Guide

Choose optimal pharmacological interventions

Trial the lowest effective dose for the shortest duration. Monitor effectiveness and tolerability using the BSMT
BEHAVIOUR AND SYMPTOM MAPPING TOOL (BSMT)
Check the Centre for Effective Practice’s Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide
Centre for Effective Practice: Use of antipsychotics in Behavioral and Psychological Symptoms of Dementia (BPSD) Discussion Guide

Learn from your peers

Consult with Behavioural Supports Ontario
Behavioural Supports Ontario
Check the Choosing Wisely Canada Toolkit for Reducing Inappropriate Use of Antipsychotics in LTC
Choosing Wisely Canada Antipsychotics Toolkit