Most antipsychotics were never designed for people with dementia—but that hasn’t stopped them from being widely prescribed among seniors to deal with behavioural symptoms such as wandering, aggression and agitation.
The drugs came on the market to treat people with major psychiatric disorders, such as schizophrenia and bipolar disorders—and they’ve been very helpful in managing those conditions, allowing many people with them to live in the community.
It’s the off-label use among dementia patients that’s concerning. Despite the fact that no antipsychotics are approved for use to treat the behavioural symptoms of the condition in the United States and only one, risperidone, has been approved for use in Canada, they’re commonly used to treat dementia patients north and south of the border.
“The general feeling is that while they’re widely used, there’s relatively little evidence to demonstrate their benefit in people with dementia,” says Dr. Paula Rochon, a geriatrician and vice president of research at Women’s College Hospital in Toronto who’s spent her career focused on improving the use of medications to treat older adults.
“There’s little to support that they work to address behavioural issues.”
While a new generation of the drugs introduced in the 1990s reduced some of the risks associated with older versions, research and clinical experience has shown that while they may be safer, they’re not necessarily safe, Rochon says.
“The promise of something that was going to be risk-free failed to materialize.”
Risky Side Effects
People who take antipsychotics can become unsteady. Given that people with dementia tend to be elderly, that heightens the risk of falls and hip fractures. Another concern is stiffness, known as Parkinsonism. People develop the features that would be present in someone with Parkinson’s—the shuffled gait, the rigidity—and can end up being treated for this new condition.
Anything that leaves an elderly person less mobile is not a good thing. The more they’re sitting or lying down, the greater their risk of infection and pressure ulcers.
“You want to keep them as active and functional as possible. It’s good for their lungs and general well-being,” Rochon says.
Using antipsychotics in this population also carries a risk of death.
Manufacturer and government warnings were issued for antipsychotics starting in the early 2000s, but Rochon says clear guidance on alternatives was lacking, so it was hard for people to know what they should do instead. Studies have shown the increased use of antipsychotics continued even after the warnings were issued.
So Why Has Their Use Become So Prevalent?
“The short answer is that right now we don’t have a single drug therapy that’s safe and effective in managing behaviour problems in dementia, so people go to other things,” Rochon says.
“People need to get away from the idea that there is going to be a single cure-all. It’s taken a while, but I think it’s happening now; there’s awareness of the problem.”
Although antipsychotics are still widely used, people are starting to think differently. They’re gravitating toward other solutions to behaviour issues and sharing best practices to give people alternatives.
In a study of Ontario long-term care homes, Rochon’s team found that about a third of residents at any point in time were on an antipsychotic. Rates of use varied greatly, ranging from 20% in some homes to more than 40% in others. Given that the homes all had similar clienteles, Rochon says that tells her that the culture of an organization is a factor in rates of use.
“While we may not know what the number should be, there are opportunities to think differently and use antipsychotics in only the most severe cases.”
Creating a culture where staff buy into the idea that there are things beyond drugs that can be used to handle minor behaviour problems is key. Training can help staff notice what might be triggering a behaviour. If people are acting out or upset, is it because they’re in pain? Constipated? Lonely? Are other things that are more treatable feeding into their behaviour? If a resident likes to be up at night and wandering, how do you make that safe?
In one study in the U.K., staff in nursing homes were trained to look for alternatives to drugs and reduced the use of antipsychotics by 20% in 12 months. At the same time, they saw no increase in behaviour issues. The Middlechurch Home of Winnipeg saw similar results.
“I commend organizations that take it upon themselves,” Rochon says. “It shows that these results can be achieved—and it leads to a better quality of life for everyone.”
In a time when health dollars are at a premium, there are savings to consider, as these drugs are quite expensive.
“And what about the cost of a hip fracture or a pressure ulcer? They’re very big costs from a quality-of-life perspective and for the system,” Rochon says.
She says people are starting to put emphasis on thinking creatively—and that’s an achievement. Organizations are sharing guidelines and models of care others can follow. Data and measures also have a key role to play in monitoring efforts, benchmarking and creating a deeper understanding.
“We’re in a place where we have to recognize that dementia is something that does happen and we need to be planning for it. With an aging population, these are exactly the type of people that are going to be in long-term care,” Rochon says. “It’s our parents. We need to think about what we want for them.”