Candy at the Nursing Home?

Just over half of seniors in residential care facilities in BC are prescribed anti-psychotic medication. Let me repeat that so that the number really sinks in. 50.3% of our parents, grandparents or spouses who live in residential care were prescribed an anti-psychotic drug in the past year (April to June 2011) costing a total of nearly $9.3 million. That is an incredibly sobering number.



The report, recently released by the BC Ministry of Health, examined the extent of antipsychotic medication use in residential care facilities by reviewing relevant literature, but also by holding focus groups with family members and stakeholders. The hard numbers come from examining the PharmaNet data, an administrative database that contains information on all prescriptions provided in the provinces. But what prompted the report?

While not specifically identified, there was some vague reference to public concerns and to a complaint from a lady whose mother was in a Fraser Valley residential facility. This could be in reference to a CBC article released in February of last year in which Doreen Bodnar revealed that her mother, Hilda Penner, was given anti-psychotic medication without the family’s approval. Penner, who had suffered from a stroke that left her unable to care for herself, had adverse effects from another drug in the same class which was the reason for the family’s opposition to the anti-psychotics. Despite this, records indicate that Penner was given Loxapine and several other anti-psychotic drugs over the two-year period she was in the residential care system. The drugs contributed to Penner having a major seizure, the article reports, thought the 83-year-old eventually died from natural causes in November 2010.

Bodnar recalls how her mother became almost invalid, unable to walk, and often unable to talk because she was so drugged. Penner suffered from dementia, and as is frequently the nature of dementia, could be difficult to deal with. The staff would have a hard time settling her down and she was moved through three facilities and two hospitals before her demise.

It’s not new news that people with dementia can sometimes be aggressive and difficult to manage. The course of the disease results in confusion, disorientation and behavioural disturbances such as depression, agitation and delusion. But are anti-psychotic drugs really the answer to dealing with this?

The report clearly indicates that it currently is in residential care facilities. Outside of the concerns about polypharmacy (the concurrent use of multiple prescriptions) and the increased risk of adverse effects in seniors, the report identifies concerns that anti-psychotic medication is being used as a form of chemical restraint (Insert sarcastic “Duh”). Anti-psychotics were originally developed to treat schizophrenia and other forms of psychoses, but are obviously being used to treat the behavioural and psychological symptoms of advanced dementia. While the drugs do control agitation and aggression, their use on 50% of residents should be more than just a wake up call. The term ‘chemical straight jacket’ comes to mind.

The BC clinical practice guidelines for the treatment of these symptoms are pretty clear cut. Physicians are recommended to use other environmental and psychosocial interventions first and to resort to prescribing anti-psychotics when all alternative therapies have been exhausted. And when it comes to that, should only be use at low doses, short durations and with close monitoring. So why are anti-psychotic drugs being handed out like candy in residential care facilities?

First is the recognition that the non-pharmacological approaches to dealing with the behavioural symptoms of dementia require personal attention and care which equates to time. Time which most care facilities with high staff turnover and low staff to resident ratios, do not have to spare.

Second, is that seniors with dementia require different care from other residents. Certainly, they can have difficult behavioural symptoms that can threaten the safety of staff, but some of this can be mitigated by very simple techniques that don’t always require the use of medication. From the focus group discussions, the Ministry report identifies the environment as a key contributing factor. Loud, large “institutions” are stressful for individuals with dementia, particularly when the setting is already not the familiar home they are comfortable in. Single occupancy rooms (more personal space), smaller facilities (less noise and intimidation) and more importantly, continuity of staff who provide unhurried care would go a long way (see also my post titled ‘Chocolate and Perfume’)

The report reviews several recommendations and changes made by other jurisdictions including Ontario, the US, UK and Australia. The Ministry’s final recommendations are primarily of an awareness building nature: to provide more education to staff, physicians and healthcare workers, particularly around the issue of consent; to have more oversight and monitoring of facilities, the results of which should be made public; and to work with pharmacists and physicians to monitor medication practices.

Yet, as the report itself notes, all the health authorities examined had up-to-date health policies in place regarding consent to healthcare. So even with the increased awareness about the process of consent among front line staff, without other appropriate measures in place to support them, such as adequate staffing ratios and appropriately designed environments for residents with dementia, exactly how much of a change can be expected? I predict a thicker application of guilt for family members to consent to the use of anti-psychotics. And for those who don’t, the whole issue can be circumvented by sending violent patients to the hospital where they are certified under the Mental Health Act and involuntary treatment can be administered without consent of the patient or the decision maker.

The province has taken a first encouraging step in the public release of this report. Let’s hope it follows through with stronger recommendations and what was learnt through Hilda Penner.