‘Not an illness or a symptom, but a person’
All the Quebec institutions in Quebec that have a long-term care mandate – 24 Integrated Health and Social Services Centres (CISSS), Integrated University Health and Social Services Centres (CIUSSS) and one University Health Centre (CUSM) – met in Montreal on Nov. 29 and 30 to kick off a province-wide collaborative focused on driving the appropriate use of antipsychotics in long term care facilities – known as CHSLDs. Limiting the use of these medications will improve the quality and experience of care in CHSLDs for people with dementia, their loved ones and staff. Inspired by CFHI’s Appropriate Use of Antipsychotics (AUA) initiative, this collaborative, which is supported by the Quebec Ministry of Health and Social Services, is offered in close partnership with CFHI and Quebec's leading experts.
The launch of Optimizing Practices, Use, Care and Services - Antipsychotics (OPUS-AP) is a promise kept for the provincial government. “During the Forum sur les meilleurs pratiques en CHSLD, a commitment was made to improve the quality of life of residents through concrete actions, based on approaches that were proven to be effective for residents of these facilities,” said Gaétan Barrette, Minister of Health and Social Services. “The support we are lending to this innovative initiative is a testament to our efforts to offer the best possible living environment to these individuals, by adopting exciting approaches that foster their overall well-being.”
According to CFHI President Maureen O’Neil, the overuse of these medications is an issue across Canada – and around the world – but there is hope. “In 2015-16, about 24% of residents of Canadian long-term care homes were on an antipsychotic without a diagnosis of psychosis, but just 5 years ago that rate was 32%,” said Ms. O’Neil. “Our experience supporting the appropriate use of antipsychotics across Canada demonstrates that it is possible to improve dementia care and reduce the inappropriate use of these medications through person-centred approaches.”
The use of these medications is particularly pronounced in Quebec. According to Dr. Véronique Dery, MD, MSc, Scientific Director, UETMISSS, CIUSSS de l’Estrie–CHUS Associate Professor, “Up to 80% of people in Quebec CHSLDs have dementia and between 40 and 60% of residents are on antipsychotics. The province has the highest rate of antipsychotic prescriptions among people 65 and older.”
“The purpose of the OPUS-AP project is to review our current procedures and ensure the appropriate use of antipsychotics in long-term care facilities,” explained Dr. Jacques Ricard, OPUS-AP Project Director mandated by the CIUSSS de l’Estrie–CHUS, and fellow of the CFHI EXTRA Program. “It is clear that we need to think critically about the medication we are prescribing, but that’s only part of the issue. Residents are evaluated based on information provided by their loved ones, and prescriptions are based on these evaluations. We are beginning to realize that there are issues with the assessment and training as well as our interpretation of residents’ needs. In some cases, antipsychotics may not be the answer. The resident might need a completely different approach.”
Turning evidence into action
At the Montreal workshop, 72 participants – including personal care attendants, physicians, pharmacists, nurses, and other providers and administrators – took part in interactive sessions designed to build their knowledge of person-centred approaches to dementia care, antipsychotic medication, change management, evaluation and other topics as part of a structured change process. The 24 teams are the first phase of this initiative that will grow to 317 homes (CHSLD) over the next 3 years.
“This is about putting our scientific knowledge into action,” said Martin Beaumont, co-CEO lead for OPUS-AP and CEO of the CIUSSS de la Mauricie-et-du-Centre-du-Québec. “Through this collaborative, we have created a highway of knowledge transfer, and by working together, we will make change happen.”
A proven approach
The appropriate use of antipsychotics (AUA) approach has its roots in work undertaken in Winnipeg, Manitoba. “Use of antipsychotics in Winnipeg residential care averaged about 30% of residents – with some homes over 50% - in 2010 when a colleague and I joined the Canadian Foundation for Healthcare Improvement’s (CFHI) EXTRA program” said Cynthia Sinclair, Regional Manager, PCH Program Accreditation and Standards Development at Interlake-Eastern Regional Health Authority, Manitoba. “We wanted to prove the power of long-term care data and we focused on RAI antipsychotics data.” The approach she and her colleague Joe Puchniak, now Director of Operations, Long Term Care, Winnipeg Regional Health Authority (WRHA) developed marries the use of data, staff education, team-based care, regular medication reviews and person-centred care strategies. “It’s important to tap into insights of anyone who interacts with the residents because they all have valuable insights,” adds Ms. Sinclair.
Their success inspired CFHI to launch a pan-Canadian collaborative in 2014 to spread this approach, reducing or eliminating antipsychotics for more than half of participating residents, while lowering falls by 20% and significantly reducing verbally and physically abusive behaviour and resistance to care by residents.
In 2016, New Brunswick was the first province to work with CFHI to scale the AUA approach through the New Brunswick Appropriate Use of Antipsychotics (NB-AUA) collaborative.
“What was captivating about the New Brunswick experience went far beyond the immediate outcomes,” said Dr. Dery. “It was the stories from family members of improved wakefulness and quality of life of their loved ones as well as the enthusiasm of staff.”
Not an illness or a symptom, but a person
Although often associated solely with memory loss, dementia – or neurocognitive disorders (NCDs) as it’s also known – can lead to significant behavioural issues. “Between 80 and 97% of people with Alzheimer’s will have some behavioural and psychological symptoms related to dementia at one point in their illness,” according to Dr. Marie-Andrée Bruneau. “These symptoms can cover a wide range from depression, euphoria, hallucination, aggressiveness, sexual disinhibition to physical agitation and more.”
It’s these behaviours that can prompt the use of antipsychotic medications like Haloperidol (Haldol), Quetiapine (Seroquel) and Risperidone (Risperidal); but there’s a growing international consensus that these medications shouldn’t be the first resort when managing BPSD (behavioural and psychological symptoms of dementia). “Do you sometimes say things that make no sense?” asked Suzanne Gilbert, B. Pharm., M. Sc., M.A.P., Assistant Manager, Pharmaceutical Care, Insitut universitaire de gériatrie de Montréal, CIUSSS du Centre-Sud-de-l’Île-de-Montréal. “If a stranger tried to remove your clothes would you resist? Consider that these behaviours in people with BPSD are similar to those of people like you and I who have no BPSD. We need to understand that residents are more than their illness and their symptoms. They are human beings.”
Communication and teamwork
Teams include a Director of Support Program for the Autonomy of Seniors (SAPA), a project lead, a nurse/physician/pharmacist/personal care attendant clinical lead, a measurement lead and a resident /family representative. Teamwork and communication was a common theme throughout the workshop, with many of the personal care attendants in the room speaking to the importance of valuing their role and intimate knowledge of residents. As one personal care attendant summed it up: “I am a personal care attendant and a healthcare professional. Trust us, we know our residents. We watch over them.”
Family members of residents were also identified as key members of the care team, with Armand Boudreau, Management Consultant and CFHI representative, noting that: "Family members are experts in the lived experiences of their loved ones.”
A solid partnership
The CIUSSS de l’Estrie – CHUS has been mandated by the Quebec government to lead OPUS-AP on behalf of all the CISSS and CIUSSS in the province. Additional partners include:
- Quebec Ministry of Health and Social Services
- Canadian Foundation for Healthcare Improvement
- Institut national d’excellence en santé et en services sociaux
- Regroupement provincial des comités des usagers
- Federation of Quebec Alzheimer Societies