When less is better

Region a leader in reducing the use of antipsychotics in personal care homes

Senior in care home

Winnipeg Health Region
Wave, May / June 2016

Like many Manitobans, Don Boschman has a loved one living with dementia. When his mother, MaryAnn, entered an out-of-province hospital for treatment, staff found that she had a tendency to wander, a behaviour which they attributed to anxiety. To combat the issue, they placed her on antipsychotic medications - medications that followed her to her subsequent placement in a personal care home.

But for Don and his siblings, the use of those powerful medications came with as many questions as they did answers.

"We saw her go into a haze, and though we were confident she was receiving quality care, we didn't know how much of her change in behaviour was due to her dementia and how much, if any, was due to side effects of the medications she was prescribed," he says.

It's a question with which many Canadians are familiar, a point underscored by a recent study conducted by the Canadian Institute for Health Information (CIHI). The study examined the use of antipsychotic medications among seniors living in long-term care (LTC) facilities across Canada in 2014.

A report on the study, entitled Use of Antipsychotics Among Seniors Living in Long-Term Care Facilities, 2014, noted that, 39 per cent of seniors in LTC facilities had at least one claim for an antipsychotic, and that nearly one-quarter of residents were chronic users of antipsychotic medications.

In December, Don and his siblings made the decision to move MaryAnn to the Bethania Mennonite Personal Care Home in Winnipeg, so that she could be closer to family. Soon after her arrival, as part of a medication review, her physician opted to discontinue two of her medications, and to significantly reduce the use of a third. The results were interesting.

"Initially, I noticed positive changes - she had been increasingly non-verbal, and I saw that she was getting a few more words out. And while that improvement turned out to be short-lived, I continued to notice that as her medications were being backed-off, I wasn't seeing any negative effects; her condition and behaviour did not deteriorate." That result left him convinced that the medication review undertaken at Bethania was a wise addition to his mother's care plan.

"Don't get me wrong, I was glad she was given those medications initially, and I know they were prescribed to her for good reasons. But I learned that conditions change, and that the reasons medications are prescribed don't always hold true over time, so I'm glad her physician didn't simply follow the path of least resistance by continuing with what had previously been prescribed. I'm glad her doctor was willing to revisit the rationale behind those prescriptions and to take a fresh look."

That kind of medication review is becoming increasingly commonplace across Canada, and especially in Winnipeg. In fact, the CIHI reportsingled out the Winnipeg Health Region for its efforts to reduce the number of personal care home residents on antipsychotic medication - a process known as de-prescribing.

The report noted that trends in the rate of antipsychotic use varied across provinces, but that "the most notable change occurred in Manitoba, where antipsychotic use decreased from 38.2 per cent in 2006 to 31.5 per cent in 2014. This was due in part to initiatives implemented by the Winnipeg Health Region to reduce inappropriate antipsychotic use in LTC facilities."

Allison Bell, Pharmacy Manager for the Winnipeg Health Region's Long Term Care Program, is pleased with CIHI's acknowledgment, adding that when residents with mental illness such as psychosis are excluded from the data, the antipsychotic usage within Winnipeg personal care homes (based on 2014-2015 data) is just over 22 per cent, about five percentage points lower than the Canadian average.

"We have such a large group of people engaged in the topic, and to have their efforts acknowledged is rewarding," she says. "This is something our Long Term Care Program cares deeply about, and that's where we find the passion and drive to continue on this journey."

As noted in the CIHI report, more than half of individuals with Alzheimer's disease and related dementias experience challenging behavioural and psychological symptoms that can include delusions, aggression and agitation. Over time, the use of antipsychotic medications to help manage these symptoms has become common in long-term care facilities. However, research shows that the medications may result in significant adverse effects, including an increased risk of death, stroke, fractures and reduced quality of life. Evidence also suggests that, in many cases, residents can be taken off antipsychotics without a negative impact on their behaviour.

"Certain behaviours can be distressing, disturbing or dangerous, and there are certainly times, even when treating dementia, where antipsychotic medication is required," Bell says. "But as with any medication, the use of antipsychotics comes down to the question of whether the benefits outweigh the risks."

The Region began to focus on dementia care when the P.I.E.C.E.S. approach was adopted and delivered in collaboration with Manitoba Health and the Alzheimer Society of Manitoba. The P.I.E.C.E.S. approach looks to understand the meaning behind a person's behaviour considering Physical, Intellectual, Emotional, Capabilities, Environment and Social aspects. Health-care providers are empowered to develop creative methods that address each resident's needs, recognizing that all behaviour has meaning. Medications such as antipsychotics are used only as a last resort.

"We started our P.I.E.C.E.S. training in 2008," Bell says, "and that's when we started to see some decline in the use of antipsychotic medication in favour of non-pharmacological approaches."

Subsequent efforts included two projects completed as part of the Canadian Foundation for Healthcare Improvement (CFHI) EXTRA program.

A two-year pilot project at Middlechurch Home of Winnipeg, completed in 2012, combined intensive P.I.E.C.E.S. education and unit team "huddles," which bring members of a resident's health-care team together to brainstorm solutions to concerns related to dementia care. The project resulted in an approximately 25 per cent drop in antipsychotic usage at that facility.

From 2013-2014, the "Blazing a TRAIL (Team Review of Antipsychotics in LTC) Towards Improved Resident Care" project focused on collaboration between physicians, pharmacists and nurses at the quarterly medication reviews to reassess the use of antipsychotic medications at three Winnipeg personal care homes: Oakview Place, Tuxedo Villa, and Heritage Lodge. Antipsychotic medications were discontinued or reduced in 56.5 per cent or 65 residents in the project.

Both projects made use of data from the Resident-Assessment Instrument - Minimum Data Set (RAI-MDS), which monitors antipsychotic medication use within the personal care homes in the Region.

"After these projects ended, we wanted to be able to sustain and share everything we'd learned," Bell says. "So in September 2014, we brought all of our efforts together under our Dementia Care Program, which provides education and training in a more intensive, inclusive and coordinated format."

The goal is to bring the program to all 38 personal care homes in Winnipeg by December, 2018.

"The most successful homes in the program have embraced it as an important cultural and organizational shift," Bell says. "They've worked hard to make it their own and are achieving impressive results."

One such participant is the Bethania Group, which has introduced the Dementia Care Program to its Bethania Mennonite Personal Care Home and Pembina Place Mennonite Personal Care Home facilities.

"The Bethania Group is focused on providing resident-centred care," says Doris Furtado, Acting Director of Resident Services, Bethania Group. "Participating in the Dementia Care Program assists us in meeting that goal by increasing our access to the P.I.E.C.E.S. tool as an investment in dementia education for not only our nurses, but for our support staff as well."

The results speak for themselves.

"At Bethania Personal Care Home, we've reduced antipsychotic use from 15.5 per cent at the start of the project to 11.5 per cent in just six months," Furtado says. "At Pembina Place, we were at 14 per cent, and we've reduced it to seven per cent. We still have six months to go, but we've come quite far."

Jennifer Ewatski, Bethania's Director of Clinical Information Systems, says the key to the success of the program is the ability to apply a person-centred model using a team-based approach where all staff can contribute their ideas.

"In our huddles (staff meetings), we're focused on the question of 'who is this person and what are their needs?'" Ewatski says. "Nursing, dietary, housekeeping, recreation, maintenance and members from different departments come together to offer up potential strategies for managing a resident's behaviour. With the benefit of the training they've received, they are more comfortable sharing their observations and suggestions. And the care plans developed with their input have more clout. We show them our data, and they can see for themselves how their hard work has been paying off."

Furtado agrees, adding that the team approach results in greater creativity and sensitivity in managing resident behaviours. "We're thinking out of the box instead of just requesting medication when a resident's behaviours are escalating," she says.

As an example, Furtado points to a resident who, in the evenings, began tearing wallpaper from the facility's hallways. With some investigation, staff discovered that the resident used to be a handyman. So instead of calling for medication, staff turned his efforts to their advantage.

"It's what he used to do in his spare time," Furtado says. "So, because we needed to redecorate anyway, we let him do it. He felt he was on the job, helping us. And for us, it became another example of using creative strategies to deal with the responsive behaviours we see."

As a 35-year veteran at Bethania, Furtado knows it's hard for residents coming into long-term care, especially where dementia is concerned.   

"There are so many losses in terms of independence, so wherever you can give back some control, that's a plus," she says. "We have to see the whole person and open the lines of communication, not just with residents, but their families. We need to involve them in the conversations about how we can deal with responsive behaviours. Medications sometimes have a role to play, but we don't want them to be our first line of intervention."

Bell concurs. "The goal isn't to reduce antipsychotic use to zero, but to use them with caution and only where they are the most appropriate option. We know we still have work to do."

Mike Daly is a communications specialist with the Winnipeg Health Region.

Wave: November / December 2015

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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