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Overview

Updated on November 17, 2015

“Ontario's popoulation is aging and so too are the number of seniors living with dementia and other complex health needs. These seniors need and deserve quality patient-centered care.”
The Honourable Deb Matthews, Minister of Health and Long-Term Care

Issue

For some residents of Ontario’s long-term care homes, antipsychotic medications improve quality of life and reduce suffering. But for others, these drugs may bring more risks than benefits. Antipsychotic medications are often used to treat psychosis, a term used to describe the hallucinations and other behaviours that frequently occur in people with conditions such as schizophrenia and bipolar disorder. These medications may also be effective at relieving symptoms such as agitation and aggression, and can improve quality of life in people with dementia.1-3

Across Ontario, there has been a slight decrease over four years in the overall percentage of long-term care home residents using an antipsychotic medication, from 32.1% in 2010 to 28.8% in 2013, but this finding does not tell the whole story. There is wide variation in the proportion of residents using an antipsychotic medication across long-term care homes, from no residents in some to more than 60% in others (Figure 1).4

Figure 1:Source: Health Quality Ontario. Looking for Balance: Antipsychotic medication use in Ontario long-term care homes.
Toronto: Queen’s Printer for Ontario; 2015.


Older people with cognitive impairments due to mental health problems, addictions, dementia, or other neurological conditions often exhibit responsive or challenging behaviours. These behaviours are known as "responsive" due to circumstances related to the person’s condition or a situation in his or her environment. Responsive behaviours include wandering, resistance to care, or behaviours that are verbally abusive, physically abusive, socially inappropriate or disruptive. In long-term care homes, these behaviours are stressful for the person presenting the behaviour, their caregivers, and other residents.

The good news is that responsive behaviours can be reduced using strategies that do not involve prescribing antipsychotics. It is understood that these behaviours are triggered (or are “responsive”) to environmental cues, such as loud noises or fast movements, and therefore minimizing these cues can help create a safer, more enjoyable home environment for all. The triggers and respective solutions for each resident are unique to the person, and therefore homes must invest more time learning about, and addressing, the concerns for each resident individually. Quality improvement responsive behaviours change ideas in long-term care homes can help address the root causes of the problem.

Call to Action

The percentage of residents using an antipsychotic medication has decreased over the past four years and this is a favourable trend. However, the substantial variation across regions and long-term care homes highlights the challenges for system-wide improvement.

Many long-term care residents in this province are using these drugs. There is substantial variation across homes in the percentage of residents with a prescription for an antipsychotic medication and this includes 12% of residents without dementia or psychosis that have a prescription for antipsychotic medication.4 These findings show the opportunity to further improve residents’ quality of life across Ontario.

  1. Herrmann N. Recommendations for the management of behavioral and psychological symptoms of dementia.

    The Canadian Journal of Neurological Sciences. 2001;28(S1):S96-S107.

  2. Steinberg M, Lyketsos CG. Atypical antipsychotic use in patients with dementia: managing safety concerns.

    American Journal of Psychiatry. 2012;169(9):900-906.

  3. Jeste DV, Blazer D, Casey D, Meeks T, Salzman C, Schneider L, Tariot P, Yaffe K. ACNP white paper: Update on use of antipsychotic drugs in elderly persons with dementia.

    Neuropsychopharmacology. 2008;33(5):957-970.

  4. Health Quality Ontario. Looking for Balance. Antipsychotic medication use in Ontario long-term care homes. 2015.

    Available at: http://www.hqontario.ca/portals/0/Documents/pr/looking-for-balance-en.pdf

Best Practices

Updated on November 17, 2015

“Insanity is doing things the way we’ve always done them and expecting different results.”
Albert Einstein

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.6 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.

To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach. 

Change ideas are specific and practical changes by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

  1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care.

    Lancet. 2003 Oct 11;362(9391):1225-30.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747

Measurement

Updated on November 17, 2015

“Some is not a number, soon is not a time.”
Don Berwick, former President and CEO of IHI, December 2004, at launch of the 100,000 Lives Campaign

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Type of Indicator Indicator of Quality Improvement How to Calculate:

numerator
__________

denominator
Targets/ Benchmarks How is This Indicator Used?
Outcome The percentage of residents on antipsychotics without a diagnosis of psychosis. Resident who received antipsychotics on their target assessments*
Residents with valid assessments
Targets: As low as possible (set by individual institutions)

Provincial benchmarks:
not available
Quality improvement

QIP indicator
*Inclusions:
1. Residents with valid assessments. To be considered valid, the target assessment must:
a. Be the latest assessment in the quarter
b. Be carried out more than 92 days after the Admission Date
c. Not be an Admission Full Assessment
2. Residents who received antipsychotic medication on one or more days in the week before their target assessment (O4a = 1, 2, 3, 4, 5, 6 or 7)
Exclusions:
1. Residents who are end-stage disease (J5c = 1) or receiving hospice care (P1ao = 1)
2. Residents who have a diagnosis of schizophrenia (I1ii = 1) or Huntington's chorea (I1x = 1), or those experiencing hallucinations (J1i = 1)
or delusions (J1e = 1)


Inclusions:
1. Residents assessments. To be considered valid, the target assessment must:
a. Be the latest assessment in the quarter
b. Be carried out more than 92 days after the Admission Date
c. Not be an Admission Full Assessment
Exclusions:
1. Residents who are end-stage disease (J5c = 1) or receiving hospice care (P1ao = 1)
2. Residents who have a diagnosis of schizophrenia (I1ii = 1) or Huntington's chorea (I1x = 1), or those experiencing hallucinations (J1i = 1)
or delusions (J1e = 1)


Run Charts

Collected measures can be presented graphically by plugging the monthly results into run chart.

Tools & Resources

Updated on November 17, 2015

Tools

Responsive Behaviours
QI Tools

 

For a more comprehensive list of tools and resources, visit the following links on our HQO website:


 

Resources

Responsive Behaviours
QI Resources