November 2018

The use of antipsychotic medications in seniors who exhibit behavioural and psychological symptoms of dementia (BPSD) has always been troubling, for both caregivers in long term care facilities and loved ones. For this reason, a project on reducing the use of antipsychotics whenever possible was met with great interest. To date, the project has not disappointed.

In 2017, with the support of the Canadian Foundation for Healthcare Improvement (CFHI), and alongside partners including the Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l’Estrie – CHUS (representative) and the Centre intégré de santé et de service sociaus (CISSS) and CIUSSS from Québec, the Ministère de la Santé et des Services Sociaux (MSSS), the Institut national d’excellence en santé et en services sociaux, the Regroupement provincial des comités des usagers, and the Federation of Quebec Alzheimer Societies joined forces to help establish a Quebec-wide project titled Optimizing Practices, Use, Care and Services—Antipsychotics (OPUS-AP).

Josée Prud’homme is a manager and local project manager for the CISSS Montérégie-Ouest. She describes her experience at the Centre d’hébergement de Coteau-du-lac long term care facility.

“In my 20 years of experience in geriatrics, I have never seen as powerful a driver as OPUS-AP for improving practices related to the use of antipsychotics for this clientele,” said Prud’homme. “The fact that we can review and update our practices and reduce or eliminate these medications is very encouraging, given that their use is linked to an increased risk of cardiovascular events, drowsiness, falls, and other adverse effects.” The pharmacological approach is still too often a first response, as it is quicker and presumed to be effective. However, we have known for several years that non-pharmacological approaches must be given priority, since there is a lack of evidence to support their effectiveness and a risk that they can cause significant side effects such as confusion, dizziness and stroke.

“You need a healthy dose of open-mindedness and creativity. It’s very exciting to see the practice evolve for the betterment of our clientele.”

Josée Prud’homme, manager at the CISSS Montérégie-Ouest, local OPUS-AP project manager

Des interventions non pharmacologiques adaptées à chaque résident et à chaque situation ne sont pas toujours évidentes à trouver. La solution ? OPUS-AP fait appel à l’expertise de tous les intervenants afin de trouver les meilleures solutions.

The pharmacological approach is still too often a first response, as it is quicker and presumed to be effective. However, we have known for several years that non-pharmacological approaches must be given priority, since there is a lack of evidence to support their effectiveness and a risk that they can cause significant side effects such as confusion, dizziness and stroke.

Non-pharmacological interventions that are adapted to each resident and each situation are not always easy to find. The solution? OPUS-AP relies on the expertise of all care providers to pinpoint the best solutions.

“For example,” added Ms. Prud’homme, “a personal support worker made an observation that helped the team understand the cause of a resident’s agitation. This collaboration led to an effective solution that would otherwise never have been considered.”

“OPUS-AP does not provide more human resources” she pointed out. “But better contact, observation, and communication with residents don’t necessarily take more time. Its positive effects can even save time with BPSDs because it’s always quicker to prevent a behaviour than to defuse one.”

For the team taking part in the project at the Centre d’hébergement Coteau-du-lac, the most eye-opening part of the OPUS-AP project was the organization of weekly clinical huddles to discuss the situations of one or two residents who could benefit from deprescribing. A checklist, or “visual station,” was created to support the approach and to act as a reminder on the appropriate use of antipsychotics. This checklist includes the list of behaviours which might call for antipsychotics, a description of the basic approach and non-pharmacological intervention methods for each resident.

How many people have benefitted from the project? “In addition to all the residents who have been successfully deprescribed, either in part or in full, once staff began to enhance their skills to better understand and prevent BPSDs, we were all winners,” said Josée Prud’homme.

Now, the greatest challenge is to ensure the project’s sustainability. The appropriate use of antipsychotics must be embedded into the day-to-day practices of every long term care facility. “The simple fact of having to report to other bodies on the project’s evolution speaks to its thoroughness and ensures its endurance. Now we need to think about the resources that should be implemented to ensure the consolidation and continuation of this change,” said Josée Prud’homme.

Integration of the OPUS-AP Project in all long term care facilities will proceed in three phases

  • Phase 1 (2018) = 1 long term care facility per CISSSO/CIUSSS = 24 in total
  • Phase 2 (2019-2020) = 132 long term care facilities (318 units)
  • Phase 3 (2020-2021) = 100% of the 317 long term care facilities in Quebec

 

Advantages of deprescribing antipsychotics in long term care facilities

 

For seniors

  • Reduced anxiety and risk of depression
  • Greater independent living skills
  • More control over their own life
  • Recognition of their habits and experience
  • Reduction in falls and other adverse effects.

For loved ones

  • Reduced sense of powerlessness
  • Knowledge on how to better intervene with the senior

For caregivers

  • Greater satisfaction and confidence at work
  • Greater sense of competence
  • More time to intervene with residents

* For the proportion of prescribed antipsychotics. Between 40% and 60% of residents in long-term care facilities aged 65 and older are prescribed antipsychotics, even without a diagnosis of psychosis.

SOURCE : Final OPUS-AP and CIUSSS de l’Estrie-CHUS poster
https://www.santeestrie.qc.ca/a-propos/projets-majeurs/reduire-les-antipsychotiques/