Program to curb antipsychotic use sees early success with continuing care patients

An effort to cut the number of Yukon continuing care patients who are taking powerful antipsychotic drugs has seen promising results so far.

An effort to cut the number of Yukon continuing care patients who are taking powerful antipsychotic drugs has seen promising results so far.

Reagan Gale, the director of clinical psychology for continuing care at the department of health and social services, has been overseeing the effort since it launched last fall.

“It’s been going really well,” she said. “We’ve had great successes.”

“When we started the initiative, in the fall, we had more than half of the residents on our pilot unit taking antipsychotic medications. And those were residents that didn’t have symptoms of psychosis. As of the end of January, we were down to around 20, 27 per cent of the residents on that unit taking those medications. Which is still higher than best practice, but is a huge improvement and puts us solidly in keeping with the national average.”

The Yukon initiative is part of a Canada-wide effort that spans 15 jurisdictions, funded through the Canadian Foundation for Healthcare Improvement.

Gale clarified that it’s not just a matter of cutting off people’s meds. “It’s not like a slash and burn, it’s not like we go in and just take everybody off their medications in one fell swoop,” she said. It’s a gradual reduction, with careful monitoring, over the course of weeks. “It’s very deliberate.”

Staff spent the summer gathering baseline data and assessing which residents might be the best candidates for medication reduction. The patients participating in the pilot phase of the program are all residents of the special care unit at Copper Ridge Place. That’s a secure unit – a locked unit, in other words – for residents, most often with dementia, who exhibit what Gale called “our most challenging and complex behaviors.”

The success with that unit bodes well for the future of the program. “If the teams can work with these residents with less antipsychotic medication, less sedation, than we can do it anywhere,” said Gale. Twenty-nine per cent of the Yukon’s continuing care residents are taking antipsychotics.

Antipsychotics were developed in the 1950s and 1960s, and were initially designed for use as anesthetic during surgery. But, researchers soon discovered, they also reduced the frequency and intensity of hallucinations and delusions. Today they’re best known as the medication for conditions like schizophrenia.

But things have come full circle, and drugs that were first intended as sedatives are now, sometimes, being employed that way again.

“Folks with schizophrenia who take these medications will say that they don’t want to take them anymore because they’re so sedating,” said Gale. “They feel woozy and dulled all the time.”

It’s those properties that result in the drugs being prescribed to patients who aren’t experiencing psychosis. Often, the prescription results from a patient experiencing a temporary health crisis.

“Have you ever had a fever that was so bad or so high that you got kind of delirious?” Gale asked, to try to explain how so many patients who don’t suffer from psychosis wind up on antipsychotics. “If you are suddenly acutely ill, and in our resident population often that’s a bladder infection or pneumonia… you can get delirious. And when you’re delirious, you can hallucinate. And sometimes, people in that delirious state can resist care.” The patient might not understand that they’ve been hospitalized, for instance, and can fight back against doctors and nurses in their confusion and pain.

“It’s appropriate to use antipsychotic medications when somebody is acutely delirious,” said Gale. That allows medical staff to treat the underlying issue. But then, she added, “for whatever reason, sometimes those medications aren’t changed.”

Sometimes it’s the patient’s family that resists phasing out the drugs. They might say “Even though mom is better now, I don’t want you changing her medication because I never want to see her as upset as she was,” Gale described as an example.

Other patients might want to continue the use of antipsychotics as a sleep aid. “Sometimes that’s absolutely the best thing, and sometimes there are other ways we can help support somebody with sleep.”

The program goes beyond the simple reduction of medication use. Everyone from medical practitioners to Copper Ridge Place maintenance and kitchen staff has received additional training in dementia care and understanding the role, and limitations, of antipsychotics.

“I’ve worked in a lot of jurisdictions,” said Gale, “and I have really not seen teams as committed and compassionate and engaged as I’ve seen in the Yukon”

“Everybody’s pretty committed. Nobody wants to see residents who are sedated when they don’t need to be. We all want the best quality of life for the people we work for.”

The eventual goal is to expand the program across all four of the territory’s continuing care residences. The Thompson Centre is up next.