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Policy changes and educational supports help spur a decrease in inappropriate use of antipsychotics and restraints

In long-term care, seniors with dementia are at higher risk of being physically restrained and given potentially inappropriate antipsychotic drugs than other seniors. However, policy changes, along with significant culture change programs in long-term care homes, have helped spur a decrease in this trend over the past several years.

As dementia progresses, seniors may need to move to long-term care homes (also called nursing homes) if they can no longer be supported at home. About one-third of seniors younger than 80 who’ve been diagnosed with dementia live in long-term care homes. The proportion increases to 42% for those 80 and older, CIHI analysis finds.

The use of physical restraints (such as wheelchair lap belts or bed rails) and potentially inappropriate antipsychotics often reflects the challenge of caring for residents with combined physical and mental illnesses and challenging behaviours.Reference1Reference2

“It’s a double challenge. In addition to managing behaviours, the loss of cognition in seniors with dementia means their loss of ability to walk or do activities of daily living. Many of the residents need to be fully supported with feeding, toileting, cleaning their mouth, dressing, etc. The most frequent challenging behaviour is refusing care,” said Nancy Cooper, director of quality and performance at the Ontario Long Term Care Association.

 

Learn more about improvement in the use of daily restraints and potentially inappropriate antipsychotics among seniors with dementia in long-term care.

Read about some examples of policy changes that are improving the quality of care for residents with dementia in long-term care facilities.

Get a broader look at some of the challenges that staff in long-term care facilities face when caring for seniors with dementia.

Examine the variation in results for quality indicators like use of daily physical restraints, potentially inappropriate use of antipsychotics and falls among seniors with dementia.

 

Policy focus and educational supports help improve trends

Although the use of daily restraints and potentially inappropriate antipsychotic drugs among long-term care residents with dementia remains a concern, the policy focus and educational supports of the past 5 years have helped improve trends.

Trends in restraint use among seniors with dementia improve over 5 years

Restraint use, decrease from 2011 to 2015: seniors with dementia, 17% to 7% in Ontario, 16% to 9% in Alberta, 13% to 10% in B.C. Seniors without dementia, 6% to 2% in Ontario, 8% to 4% in Alberta, 8% to 6% in B.C.

Restraint use among seniors in long-term care, percentage, 2011–2012 to 2015–2016 (unadjusted rates)

Restraint use among seniors with dementia decreased between 2011 and 2015, from 17% to 7% in Ontario, from 16% to 9% in Alberta and from 13% to 10% in B.C.

Source
Continuing Care Reporting System, 2011–2012 to 2015–2016, Canadian Institute for Health Information.

Trends in potentially inappropriate antipsychotic use among seniors with dementia improve over 5 years

Potentially inappropriate antipsychotic drug use, decrease from 2011 to 2015: seniors with dementia, 38% to 26% in Ont., 34% to 21% in Alta., 40% to 31% in B.C. Seniors without dementia, 13% to 10% in Ont., 12% to 9% in Alta., 16% to 13% in B.C. This decrease was more pronounced among seniors with dementia than those without.

Potentially inappropriate antipsychotic use among seniors in long-term care, percentage, 2011–2012 to 2015–2016 (unadjusted rates)

Potentially inappropriate antipsychotic drug use among seniors with dementia decreased between 2011–2012 and 2015–2016: from 38% to 26% in Ontario; from 34% to 21% in Alberta; and from 40% to 31% in B.C. This decrease was more pronounced among seniors with dementia than those without.

Source
Continuing Care Reporting System, 2011–2012 to 2015–2016, Canadian Institute for Health Information.

 

Examples of policy changes and educational supports

Policy changes and educational supports have focused on training staff to use a person-centred care approach to address challenging behaviours.Reference2Reference3 Person-centred care focuses on the individual rather than the dementia, and builds on a person’s strengths and abilities rather than losses.Reference4

Among the policy changes is Ontario’s Long-Term Care Homes Act, which requires long-term care homes to reduce the use of restraints (both chemical and physical) wherever possible. In response, Behavioural Supports Ontario (BSO) launched a team-based program in 2010. This program enhances health care services for Ontario’s seniors, their caregivers and their families who are living and coping with responsive behaviours associated with dementia and other illnesses.Reference2 Responsive behaviours include verbal abuse, physical abuse, socially inappropriate or disruptive behaviour and resisting care.

Behavioural Supports Ontario provided specific skill set training to a few staff in the long-term care homes in Ontario. The staff became the in-house experts to spread the knowledge. They helped others to replicate what they do. Where these teams are embedded, everyone in the home is better adapted to manage the care of seniors living with dementia. — Nancy Cooper

Support with appropriate prescribing of antipsychotics was provided by the Ontario Ministry of Health and Long-Term Care, the Centre for Effective Practice and Health Quality Ontario. A significant number of long-term care homes participated in this project, as well as in a national antipsychotic reduction program by the Canadian Foundation for Healthcare Improvement.

In Alberta, the Appropriate Use of Antipsychotics (AUA) Initiative informed and was reinforced by amendments to the Continuing Care Health Service Standards. It was a quality improvement initiative that enabled a multi-year scale and spread project that started in long-term care, led by the Alberta Health Services Seniors Health Strategic Clinical Network (funded by Alberta Health). The 2016 Continuing Care Health Service Standards requirement for monthly reviews of antipsychotics used as restraints is key to enabling antipsychotic reductions.Reference5

British Columbia’s Continuing Care Health and Safety Association, SafeCare BC and the Alzheimer Society of B.C. partnered to bring dementia care training to staff in the province’s continuing care sector. The goal was to improve quality of resident care and enhance staff safety by using person-centred care approaches.

The changes in practices are still being evaluated, but CIHI analysis finds that on average the use of physical restraints and antipsychotic drugs decreased substantially from 2011–2012 to 2015–2016.

 

Challenges of caring for seniors with dementia in long-term care

Within long-term care homes, 69% of residents had dementia in 2015–2016. The proportion of those having any form of cognitive impairment (including dementia and other conditions such as stroke or trauma) was 87%.

“The population in long-term care has changed rapidly over the past 5 years to be the population with moderate to severe dementia. What we know now is that if you are in long-term care, you have cognitive impairment,” said Cooper.

It can be quite challenging to provide care for residents with dementia in long-term care homes. In addition to severe cognitive impairment (40% of residents), 50% had responsive behaviours, 31% had signs of depression and 82% required extensive assistance or were dependent for activities of daily living.

 

Caring for residents with dementia can be challenging

Characteristics of seniors with dementia in long-term care, 2015–2016
Characteristics % among residents with dementia

Source
Continuing Care Reporting System, 2015–2016, Canadian Institute for Health Information.

Severe cognitive impairment (Cognitive Performance Scale ≥4) 40%
Any responsive behaviours (Aggressive Behaviour Scale ≥1) 50%
Signs of depression (Depression Rating Scale ≥3) 31%
Dependence in ADLs (Activities of Daily Living Hierarchy Scale ≥3) 82%
Some indication of health instability (Changes in Health, End-Stage Disease, and Signs and Symptoms Scale ≥1) 59%
Wandered at least once in the last 7 days 21%
Were admitted to hospital at least once in the last 90 days 6%
Had visited emergency room at least once in the last 90 days 4%

To review characteristics of seniors with dementia receiving home and community care, refer to the table Caring for individuals with dementia can be challenging.

 

Results for quality indicators in long-term care vary

Quality indicators provide important information about aspects of health such as function, safety and quality of life. The results are used to improve and enhance quality of life for long-term care residents.Reference6

Despite substantial improvements in reducing the use of restraints and antipsychotics, long-term care residents with dementia had less desirable results for a few quality indicators (unadjusted rates) compared with other residents. In particular, in 2015–2016, for residents with dementia,

  • The percentage given antipsychotics (without a diagnosis of psychosis) was more than double that for residents without dementia (27% versus 11%)
  • Restraints were used on a daily basis for individuals with dementia more frequently than for those without (9% versus 3%)
  • The percentage who fell was higher than that for residents without dementia (16% versus 11%)

For some quality indicators — such as infections, new pressure ulcers, and worsened mood or symptoms of depression — the results were comparable for residents with and without dementia.

 

Results of quality indicators for seniors in long-term care vary by dementia status

Quality indicators for seniors with and without dementia in long-term care, 2015–2016 (unadjusted rates)
Quality indicator (unadjusted rates) With dementia Without dementia

Source
Continuing Care Reporting System, 2015–2016, Canadian Institute for Health Information.

Taken antipsychotics without a diagnosis of psychosis 27% 11%
Daily physical restraints 9% 3%
Has fallen 16% 11%
Worsened or remained dependent in mid-loss ADLs (transfer or locomotion) 40% 32%
Worsened cognitive ability 12% 9%
Worsened behavioural symptoms 14% 8%
Has 1 or more infections 9% 11%
Worsened stage 2 to 4 pressure ulcer 3% 3%
Has a new stage 2 to 4 pressure ulcer 3% 3%
Worsened mood symptoms of depression 23% 22%