Health Quality Ontario

Long-Term Care

Antipsychotics

Best Practices

Updated on October 02, 2017

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

Percentage of long-term care home residents without psychosis on antipsychotics in the last 7 days is a priority indicator for the QIP. This indicator measures the percentage of long-term care home residents without psychosis using antipsychotic medication. A lower percentage is better. In Ontario 22.9% of long-term care residents not living with psychosis were given antipsychotic medications during 2015/2016.

Below are evidence informed best practices for reducing the percentage of potentially inappropriate prescribing of antipsychotics in long-term care. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible. They are graded according to Type of Evidence.

To help you move from best evidence to best practice you can join the Long-Term Care Community of Practice hosted by Health Quality Ontario, or refer to the report Looking for Balance: Antipsychotic medication use in Ontario long-term care homes, or browse the interactive table below for a quick summary of how to improve on potentially inappropriate antipsychotic use.

  1. Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P; British Geriatric Society.
    Guidance on the management of pain in older people.
    Age Ageing. 2013 Mar;42 Suppl 1:i1-57.

  2. Brodaty H, et al.
    Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia.
    Am J Psychiatry. 2012 Sep;169(9):946-53.

  3. Bakker T J, Duivenvoorden HJ, van der Lee J, Olde Rikkert MG, Beekman A T, Ribbe MW.
    Integrative psychotherapeutic nursing home program to reduce multiple psychiatric symptoms of cognitively impaired patients and caregiver burden: randomized controlled trial.
    Am J Geriatr Psychiatry. 2011 Jun:19(6), 507-20.

  4. Chenoweth L, King MT, Jeon Y-H, Brodaty H, Stein-Parbury J, Norman R, Hass M, Luscombe G.
    Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: A cluster-randomised trial.
    Lancet Neurol. 2009 Apr;8(4):317-25.

  5. Coon J.T., Abbott R., Rogers M., Whear R., Pearson S, Lang I, Cartmell N., Stein K. (2014).
    Interventions to Reduce Innapropriate Prescribing of Antipsychotic Medications in People With Dementia Resident in Care Homes: A systematic Review.
    JAMDA: 15: 706-718.

  6. Dalleur O, et al.
    Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria.
    Drugs Aging. 2012 Oct;29(10):829-37.

  7. Davison TE, Hudgson C, McCabe MP, George K, Buchanan G.
    An individualized psychosocial approach for "treatment resistant" behavioral symptoms of dementia among aged care residents.
    Int Psychogeriatr. 2007 Oct;19(5):859-73.

  8. Declercq T, Petrovic M, Azermai M, Vander Stichele R, De Sutter AI, van Driel ML, Christiaens T.
    Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia.
    Cochrane Database Syst Rev. 2013 Mar 28;3:CD007726.

  9. Deudon A, Manbourqeut N, Gervais X, Leone E, Brocker P, Carcaillon L, Riff S, Lavallart B, Robert PH.
    Non-pharmacological management of behavioural symptoms in nursing homes.
    Int J Geriatr Psychiatry. 2009 Dec;24(12): 1386-95.

  10. Eloniemi-Sulkava U, Saarenheimo M, Laakkonen ML, Pietilä M, Savikko N, Kautiainen H, Tilvis RS, Pitkälä KH.
    Family care as collaboration: effectiveness of a multicomponent support program for elderly couples with dementia: randomized controlled intervention study.
    J Am Geriatr Soc. 2009 Dec; 57(12):2200-08.

  11. Fuchs-Lacelle S, Hadjistavropoulos T.
    Pain assessment as intervention: a study of older adults with severe dementia.
    Clin J Pain. 2008 Oct;24(8): 697-707.

  12. Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck WW.
    Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention.
    J Am Geriatr Soc. 2010 Aug;58(8):1465-74.

  13. Hadjistavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, Smith JH.
    Pain assessment in elderly adults with dementia.
    Lancet Neurol. 2014 Dec;13(12):1216-27.

  14. Health Quality Ontario.
    Looking for Balance: Antipsychotic medication in Ontario long-term care homes.
    Queens Printer for Ontario, 2015. Toronto, ON.

  15. Health Quality Ontario.
    Insights into Quality Improvement, Long-Term Care Impressions and Observations 2016/17 Quality Improvement Plans.
    Queens Printer for Ontario, 2017. Toronto, ON.

  16. Hopkins RW, Kilik LA.
    Kingston Standardized Behavioural Assessment. 2015.
    Available from: http://www.kingstonscales.org/behaviour-assessment.html.

  17. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D.
    Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial.
    BMJ. 2011;343.

  18. Jablonski RA, Reed D, Maas ML.
    Care intervention for older adults with Alzheimer’s disease and related dementias: Effect of family involvement on cognitive and functional outcomes in nursing homes.
    J Gerontol Nurs. 2005 Jun;31(6): 38-48.

  19. Luttenberger K, Donath C, Uter W, Graessel E.
    Effects of multimodal nondrug therapy on dementia symptoms and need for care in nursing home residents with degenerative dementia: a randomized controlled study with 6-month follow-up.
    J Am Geriatr Soc. 2012 May;60(5): 830-40.

  20. Martinez F, Tobar C, Hill N.
    Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature.
    Age Ageing. 2015 Mar;44(2):196-204.
    Abstract available at: http://ageing.oxfordjournals.org/content/early/2009/05/21/ageing.afp039.full.pdf+html

  21. Moniz Cook ED, Swift K, James I, Malouf R, De Vugt M, Verhey F.
    Functional analysis-based interventions for challenging behaviour in dementia.
    Cochrane Database of Systematic Reviews 2012, Issue 2. Art.

  22. Ndefo U.A., Norman R., Henry A.(2017).
    Academic Detailing Has a positive effect on prescribing and decreasing prescription drug costs: A Health Plan's Perspective.
    Am Health Drug Benefits: 10(3): 129 - 133.

  23. O’Connor DW, Ames D, Gardner B, King M.
    Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards.
    Int Psychogeriatr. 2009 Apr; 21(2):225-40.

  24. Perry M, Melis RJF, Teerenstra S, Draskovic I, van Achterberg T, van Eijken MI, Lucassen P, Rikkert MG.
    An in-homegeriatric programme for vulnerable community-dwelling older people improves the detection of dementia in primary care.
    Int J Geriatr Psychiatry. 2008 Dec;23 (12):1312-19.

  25. Pieper MJ, van Dalen-Kok AH, Francke AL, van der Steen JT, Scherder EJ, Husebø BS, Achterberg WP.
    Interventions targeting pain or behaviour in dementia: a systematic review.
    Ageing Res Rev. 2013 Sep;12(4):1042-55.

  26. Schneider LS, et al.
    Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials.
    Am J Geriatr Psychiatry. 2006 Mar;14 (3):191-210.

  27. Seitz DP, et al.
    Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review.
    J Am Med Dir Assoc. 2012 Jul;13 (6):503-506.e2.

  28. Stock K.J., Amuah J. E., Lapane K. L., Hogan D.B., Maxwell C. J. (2017).
    Prevalence of, and Resident and Facility Characteristics Associated with Antipsychotic Use in Assisted Living Vs. Long-Term Care Facilities: A Cross Sectional Analysis from Alberta Canada.
    Drugs Ageing 34: 39-53.

  29. Tabet N, Howard R.
    Non-pharmacological interventions in the prevention of delirium.
    Age Ageing. 2009;38 (4):374-79.

  30. Thomas E, Smith JE, Forrester DA, Heider G, Jadotte YT, Holly C.
    The effectiveness of non-pharmacological multi-component interventions for the prevention of delirium in non-intensive care unit older adult hospitalized patients: a systematic review.
    The JBI Database of Systematic Reviews and Implementation Reports 12.4 (2014): 180-232.

  31. Vasse E, Vernooij-Dassen M, Spijker A, Rikkert MO, Koopmans R.
    A systematic review of communication strategies for people with dementia in residential and nursing homes.
    Int Psychogeriatr. 2010 Mar;22(2):189-200.

  32. Wang JJ.
    Group reminiscence therapy for cognitive and affective function of demented elderly in Taiwan.
    Int J Geriatr Psychiatry. 2007 Dec;22(12): 1235-40.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/17503545

  33. Wolfs CA, Kessels A, Dirksen CD, Severens JL, Verhey FR.
    Integrated multidisciplinary diagnostic approach for dementia care: randomised controlled trial.
    Br J Psychiatry. 2008 Apr; 192(4):300-05.

  34. Zwakhalen SM, Hamers JP, Abu-Saad HH, Berger MP.
    Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools.
    BMC Geriatr. 2006 Jan 27;6(3).

Measurement

Updated on October 02, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Percentage of long-term care home residents without psychosis on antipsychotics in the last 7 days
Topic Ageing
Quality Dimension Effective, Patient-centred, Safe
Type of Indicator Process
Measure Percentage (%)
Data Source Continuing Care Reporting System (CCRS)
Data Collection Instrument Collected by the Canadian Institute of Health Information (CIHI)
How to Calculate

The indicator is calculated using 4 rolling quarters of data and summing the number of residents that meet the inclusion criteria for the target quarter and each of the previous 3 fiscal quarters for both the numerator and denominator.


(Sum of Numerator / Sum of Denominator) x 100

Numerator: # LTC home residents in a fiscal quarter who used antipsychotic medication on 1+ days in the 7 days before their resident assessment

Denominator: # LTC home residents in a fiscal quarter with a valid resident assessment (excluding those with schizophrenia, Huntington's, hallucinations or delusions, and end-stage disease or in hospice care)

See the Indicator Library for specifics on calculating this indicator.

Target Lower is better (set by individual institutions)
Range 0 – 100%
HQO Reporting Tool Practice reports (audit/feedback), Public reporting, Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Tools & Resources

Updated on October 02, 2017

Health Quality Ontario’s Tools and Resources
Other Tools and Resources

Background

Updated on October 02, 2017

“Dementia affects the family as much as the person living with the disease. It is critical that we respond to the needs of both patient and caregiver”.
Honourable Dr. Eric Hoskins, 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 (Herrmann et al, 2001; HQO, 2015; Jeste et al., 2008; Steinberg & Lyketsos, 2012).

In Ontario the long-term care sector has made significant progress in reducing potentially inappropriate antipsychotic use across the province. The performance on this indicator has improved over the last six years from 35% in 2010/2011 to 22.9% in 2015/16.

Figure 1: Percentage of long-term care home residents not living with psychosis who were given antipsychotic medications, in Ontario, 2010/11 to 2015/16

However 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 50% in others. To view the percentages of long-term care home residents not living with psychosis who were given antipsychotic medications in individual homes use the interactive graph in System Performance.


Call to Action

Antipsychotics are often prescribed to reduce responsive behaviours which are related to a resident’s condition, situation or environment. Responsive behaviours include wandering, resistance to care, or behaviours that are verbally abusive, physically abusive, socially inappropriate or disruptive causing stress or harm to themselves, other residents, caregivers and staff. However, antipsychotics are not the only way to reduce such behaviours, the change ideas outlined in the  “Best Practices” tab can help address the root causes of this issue.

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

  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. Health Quality Ontario.
    Looking for Balance: Antipsychotic medication in Ontario long-term care homes.
    Queens Printer for Ontario, 2015. Toronto, ON.

  3. Health Quality Ontario.
    Insights into Quality Improvement, Long-Term Care Impressions and Observations 2016/17 Quality Improvement Plans.
    Queens Printer for Ontario, 2017. Toronto, ON.

  4. Jeste DV, Blazer D, Casey D, Meeks T, Salzman C, Schneider L, et al.
    ACNP white paper: update on use of antipsychotic drugs in elderly persons with dementia.
    Neuropsychopharmacology. 2008;33(5):957-70.

  5. Steinberg M, Lyketsos CG.
    Atypical antipsychotic use in patients with dementia: managing safety concerns.
    American Journal of Psychiatry. 2012;169(9):900-6.