The use of antipsychotics among older adults in long-term care (LTC) facilities has been the subject of much controversy. Healthcare professionals and family caregivers are divided on this issue. One side believes that antipsychotics work and are beneficial to patients. Still, there are others who believe that they can directly cause harm to a patient or create conditions that can put their health, safety, and well-being at risk.
What are antipsychotics?
“Antipsychotics are a group of medications that can reduce or relieve symptoms of psychosis, such as delusions and hallucinations.” (Source: Fraser Health Authority)
Antipsychotics are commonly used to treat people with diagnosed schizophrenia, bipolar disorder, major depressive disorder, and other psychotic disorders. They are used to manage symptoms of psychosis such as delusions and hallucinations.
Hallucinations and delusions can also be seen among patients diagnosed with dementia. As such, some physicians have turned to prescribing antipsychotics to patients living with symptoms of dementia.
However, it is important to emphasize that dementia is not a form of psychosis or psychotic disorder. Hallucinations, that is, seeing or hearing something (or someone) that is not there; and, delusions or false beliefs, are symptoms of dementia that may be caused by a variety of conditions.
Dementia has a different pathology and prognosis from psychotic disorders. An accurate and early diagnosis of dementia is key to getting the person the right treatment in a timely manner.
Delirium, commonly mistaken for dementia, is another mental condition wherein the patient may acutely exhibit signs of psychosis. Unlike certain forms of dementia, the causes of delirium are treatable, like urinary tract infections (UTIs). Treating the person’s UTI with antibiotics (and not antipsychotics) would often eliminate symptoms of delirium that may mimic psychotic disorders.
Therefore, it is very important to come up with the correct diagnosis in order to prescribe the most appropriate treatment, particularly for people living with dementia and older adults living in LTC facilities exhibiting difficult behaviours,
"We have to take a really hard look at the culture and practice in long-term care, and what it is that we're doing or not doing that we're defaulting to this prescribing of antipsychotics.” ~ Isobel Mackenzie, BC’s Senior Advocate
Should older adults living in long-term care facilities experiencing acute hallucinations and delusions be given antipsychotics?
Antipsychotic medications are meant to treat individuals with a diagnosed psychotic disorder. Sadly, there seems to be an overly high number of older adults in LTC facilities who are being prescribed antipsychotic medications.
According to the “Monitoring Senior Services 2021 Report” published by the Office of the Seniors Advocate in BC, during the pandemic of 2020, “Antipsychotic medications were administered to 33% of residents.” According to the same report, even more concerning is that “antipsychotic medications were administered to 27% of residents who did not have a diagnosis of psychosis.”
As a Dementia Consultant and Educator for the past 25 years, I have found that in many of my clients, most dementia-associated behaviours including those that mimic psychotic disorders can be managed using proven and evidence-based approaches. Before even considering prescribing antipsychotics to patients affected with dementia, care professionals should first ask the reason for the behaviour. This step is critical to prevent or reduce the risks brought on by the side effects of antipsychotics that could negatively impact the patient’s well-being.
“It's important to recognize that when it comes to dementia, the best way to deal with behaviours like agitation, wandering and aggression is skilled, relationship-based care, not drugs.” ~ Dr. Rita McCracken, Family Physician and Professor at the University of British Columbia (UBC)
How the misuse and overuse of antipsychotics negatively impact an older adult’s well-being
Before taking antipsychotics or any prescribed medications, it’s important that patients and their family caregivers take the time to talk to their pharmacists. The patient has a right to know the effects of the medication(s) they are putting in their bodies. Part of the dispensing fee is medical advice from the pharmacist. Some key questions the patient needs to ask their pharmacist include:
1. What are the possible side effects of the new medication?
2. How does the new medication affect or interact with the other medications being taken?
3. How long before the desired effect of the new medication will take effect?
Older adults tend to take multiple medications. Therefore, it is even more important to find out how these different medications interact with each other. For instance, citalopram, a drug commonly prescribed to treat depression, can cause headaches, sleepiness, dry mouth, dizziness, and nausea, to name a few. These side effects can increase the patient’s fall risk or reduce their appetite.
Anecdotally, as a Dementia Consultant, I have had several conversations with many of my clients on how the use of antipsychotics has negatively impacted their loved one’s well-being.
A story shared to me by one care professional is of a physically-able and active older woman who moved to a care home, and, in a matter of two weeks, had to use a wheelchair. The patient has dementia and behavioural issues. She managed her depression well with the use of anti-depressants. She had a difficult time adjusting to her new home, so the care home decided to increase her dosage. The patient became more “docile,” and stopped becoming physically active as she slept most of the time. Her friends were furious with the care home to discovering how fast their friend’s physical and mental condition quickly deteriorated.
Sadly, family caregivers are neither informed nor sufficiently informed about the medications being given to their loved ones when they are in LTC facilities. In some cases, LTC facilities would vaguely ask if they can “administer certain medications PRN or as needed.” Often, family caregivers are not fully aware of what they are consenting to on behalf of their loved ones.
"If you truly believe there is always a reason for the behaviour, then your next question will automatically be: 'Why?'. By asking this one word, you will notice how quickly your brain will enter into detective mode. Once you discover the reason why, your brain will next begin to problem solve your situation." ~ Karen Tyrell
It doesn’t take a lot of time to practice relation-based care
As Dr. McCracken stated, “The best way to deal with behaviours like agitation, wandering, and aggression is skilled, relationship-based care, not drugs.”
The misconception is that it takes a lot of time to investigate the reason for a person’s behaviour. In my experience as a Dementia Consultant, this is not the case. Asking the patient and validating their fear, frustration or emotion doesn’t take a lot of time. Sometimes, approaching a patient in a calm and caring tone is enough to help them feel seen, heard, and validated.
Have you ever been in a situation when you got increasingly agitated to the point that you feel like you want to yell or slam the door or throw your phone out of frustration? Can you recall what caused you to behave the way you did? Was it because you felt the person you are speaking with was not understanding you? Did it feel like they were not even trying to listen to you? Would medications solve this issue?
Imagine then, what it might be like for someone with dementia. Not only can they be frustrated with themselves for not being able to effectively communicate what they need, they may also be feeling scared or alone.
A few minutes of conversation can literally make a lifetime of difference in the quality of life of someone living with dementia.
Dedication
Knowledge is power. Knowledge is empowerment. Knowledge put into practice saves lives.
We would like to dedicate this article to the students and graduates of all our online dementia education programs for taking that extra mile in their education to learn more and understand dementia. They have taken one extra mile after another to use this knowledge and practice what they learned to better support their clients to achieve optimum quality of life. Their actions have created a ripple effect in dementia practice and behaviour management and inspired others to use non-pharmacologic approaches as the first-line treatment to manage dementia-related behaviours. We are grateful to all of you!
At Dementia Solutions, we’ve made it our mission to demystify dementia behaviour and empower caregivers through education. We believe that awareness creation and skill-building through education is the most effective and powerful tool we have to promote and maintain the well-being of both the person with dementia and their caregiver.
If you need support in your caregiving experience or would like to learn more about our educational opportunities, please reach out to us at Info@DementiaSolutions.ca and we would be more than happy to support you.
