Appropriate Use of Antipsychotics

Resident and Caregiver

There are more than 419,000 people in Canada aged 65 and older diagnosed with dementia; and more than 78,000 new cases diagnosed every year among this age group1. By meeting the needs of people living with dementia in their home and the community, we can improve their care experiences and lives, and the experiences of their family, care partners and providers.

Antipsychotic medications are often prescribed to help manage common responsive behaviours people with dementia experience, such as agitation and verbal or physical reactions. However, there is a lack of evidence to support their effectiveness and a risk they can cause significant side effects, including confusion, dizziness, stroke or even death.

The Appropriate Use of Antipsychotics (AUA) is a person-centred approach2 to care that engages people living with dementia, their families and care partners, and long-term care staff to understand the causes of behaviours and underlying issues (such as pain), and respond to an individual’s unmet needs based on his/her personal history. Residents benefit from having their medications reviewed and appropriately discontinued or reduced if they no longer need it, reducing their risk of negative health outcomes. This approach can also improve their care experiences and lives, and the lives of their family, care partners and staff.

AUA had its roots in the Canadian Foundation for Healthcare Improvement’s EXTRA: Executive Training Program. Cynthia Sinclair and Joe Puchniak, two managers from the Winnipeg Regional Health Authority, designed an initiative to identify long-term care residents who may benefit from non-drug therapies to treat responsive behaviours associated with dementia. As a result, 27 percent of the cohort of residents were successfully taken off antipsychotics medication without any increase in behavioural symptoms. In addition, their care experience and lives were improved, and a $400,000 savings was achieved within a six month period across the region.

CFHI worked with the original innovators to develop and deliver a pan-Canadian collaborative from 2014-2015 that implemented the AUA approach across 56 long-term care homes. Since then, through province-wide expansion in Quebec, New Brunswick, Newfoundland and Labrador, and Prince Edward Island, CFHI has supported more than 300 long-term care homes to deliver person-centred dementia care and reduce potentially inappropriate antipsychotic use.

CFHI has now partnered with the Vancouver Regional Health Authority to spread the AUA approach to 56 long-term care homes in British Columbia in 2020. We are also working with Health PEI to support to spread the AUA approach across the privately funded long-term care home sector.

How the Appropriate Use of Antipsychotics contributes to better healthcare in Canada

Teams that participated in CFHI’s AUA collaborative have consistently seen rates of antipsychotic medication use cut in half and, in the best cases, family members have told us their loved ones seem more like their old selves because they are better able to interact and participate in daily activities. Their care experiences and lives have been improved while the risk of negative health outcomes has been reduced.

Rates of potentially inappropriate antipsychotics use are declining across Canada thanks to the collaborative efforts like the AUA approach: in 2013-14, about 1 in 3 long term care residents who did not have a psychosis diagnosis was prescribed an antipsychotic3 and by 2017-18, that number had dropped to 1 in 54.

At an organizational level, teams participating in the AUA collaborative learn about using data to inform care planning, conducting regular medication reviews, working in multi-disciplinary teams, engaging families and care partners, as well as implementing person-centred approaches to dementia care.

Some staff in participating long-term care homes have reported that appropriate medication reductions in residents have created more staff time for since residents are sometimes able to eat more independently and have increased mobility. Such positive outcomes can inspire culture changes in many of the supported long-term care homes, whereby staff are considering antipsychotic medication only as a last resort and a short-term solution for treating responsive behaviours such as severe physical reactions.

The Approach

The AUA approach is a person-centred approach to care that engages people living with dementia in long-term care, their families and care partners, and staff to understand the underlying causes of behaviour and review the appropriateness of antipsychotic medication when there isn’t a diagnosis of psychosis. Together, conversations are had about a residents’ personal history, including likes and dislikes, which informs the creation of individualized care plans. The care plans often incorporate alternative activities that are meaningful and enjoyable for the resident (such as pet or music therapy), and where possible, changes in routines that respect resident preferences (such as bathing in the afternoon instead of the morning).

AUA Infographic

This image describes components of the AUA approach to care: apply deprescribing guidelines; collect and monitory data; conduct medication reviews; practice person-centred approaches to care; engage interprofessional staff and families.

In partnership with the provinces, CFHI has co-developed a series of 11 online education modules that are used by existing and new staff to support the person-centred approaches to care. We also provide coaching, learning and networking opportunities to support the spread of AUA and contribute seed funding to participating organizations.

Working with our AUA partners, we have developed and curated tools and resources to support people and organizations to better understand the use of antipsychotic medications, have conversations about their appropriate use, and support long term improvements in person-centred approaches to care.

Timeline

  • 2014-2015

    Pan-Canadian AUA collaborative
  • 2016

    New Brunswick Appropriate Use of Antipsychotics (NB-AUA) collaborative
  • 2017

    Optimizing Practices, Uses, Care and Services - Antipsychotics (OPUS-AP)
  • 2018

    Newfoundland, PEI, and SQLI Appropriate Use of Antipsychotics Spread Collaborative
  • 2020

    Continued partnership and leadership to share policy insights, identify levers for change and drive implementation

The Collaboratives

Improvement Conversation

OPUS-AP, a Powerful Driver for Improving Quality of Life in Long Term Care Facilities
Read more >

News Release

New Results: Innovative program is improving lives of seniors with dementia in Newfoundland & Labrador and Prince Edward Island
Read more >

Tool / Resource

The Antipsychotic Deprescribing Tool
Read more >

1 Public Health Agency of Canada. (2019). A Dementia Strategy for Canada: Together We Aspire. Retrieved from: https://www.canada.ca/content/dam/phac-aspc/images/services/publications/diseases-conditions/dementia-strategy/National%20Dementia%20Strategy_ENG.pdf 

2 In this context, person-centred approach refers to a way of thinking about, and improving, care where the people using healthcare services are equal partners in planning, developing and monitoring care, and ensuring it meets their needs.

Canadian Institute for Health Information. (2016). Use of Antipsychotics Among Seniors Living in Long-Term Care Facilities, 2014. Ottawa, ON. Retrieved from https://secure.cihi.ca/free_products/LTC_AiB_v2_19_EN_web.pdf 

4 Canadian Institute for Health Information [online]. Potentially Inappropriate Use of Antipsychotics in Long-Term Care. Retrieved from: https://yourhealthsystem.cihi.ca/hsp/inbrief#!/indicators/008/potentially-inappropriate-use-of-antipsychotics-in-long-term-care/;mapC1;mapLevel2;/