Reducing antipsychotic use: One home’s story

 “Our team was supportive. Our docs were motivated. They said, ‘Let’s do this!’” 

That’s how Caroline Shemilt, Director of Care at the Village of Humber Heights, describes her home’s decision to tackle its high rate of antipsychotic use in January 2014.

Six months later, the number of residents on antipsychotics in the 192–bed Etobicoke home had dropped from 32% to 18% — a rate well below the provincial average. 

Humber Heights’ success is the result of an interdisciplinary initiative led by Shemilt; Bella Patel, the home’s consulting pharmacist from Medisystem Pharmacy; and the home’s physicians, Drs. Dushan Vaithilingam and David Giddens. Launched at the beginning of last year in a 32-bed unit with the highest antipsychotic use, the initiative involved registered practical nurses (RPNs), personal support workers (PSWs), physicians, and families of the residents.

To begin the process, Patel identified the residents who were on antipsychotic medication and reviewed their medication history. A pattern quickly emerged: most were already on the medication when they arrived at the home and very few had a psychiatric diagnosis with an indication for the medication. 

“I think a lot of times residents are acutely ill prior to admission,” says Shemilt. “A person living with dementia perhaps doesn’t know why they’re in hospital or why they’re being confined. Or someone may be suffering from a delirium, which is often mistaken for a dementia due to hallucinations, calling out or agitation. Unfortunately, a large majority of these patients end up being prescribed antipsychotics.”

Once they had identified the residents, Shemilt and Patel met with the frontline team to educate them on the proper use of antipsychotics and the medication’s side effects and to review each resident’s situation. Shemilt says that in many cases, the PSWs were surprised that residents were on antipsychotics. “They would make statements like, ‘What? He doesn’t need an antipsychotic. He’s fine. He has no behaviours.’” 

Together, the team developed an approach to use with each resident and presented it to the home’s physicians. Team members also contacted the families of residents to explain the initiative. Most families were excited, but Shemilt says some initially refused to participate, because they were afraid of the agitation or of getting anxious phone calls from their loved one in the middle of the night. 

“They had had terrible experiences in the past,” she says. “But sometimes they would call back and say ‘Let’s try it again. Let’s see what happens.’” 

Medication was tapered gradually at two–week intervals and behavioural changes were tracked. The external Behavioural Supports Ontario team was also on standby if needed. Residents were reassessed every two weeks and based on staff input and conversations with the physician and family, the medication was further reduced if all was going well. 

The results surprised everyone. There were a few instances in which residents had to be returned to their original dose as a result of aggressive behaviour. But in most cases there was either no change in behaviour or the change was a positive one. Within six weeks, the team had successfully weaned six residents from the medication and reduced the dosage for eight more. Encouraged by this success, Humber Heights rolled out the initiative across the rest of the home. 

Shemilt says many residents have experienced significant improvements in quality of life as a result of the reduced antipsychotic use. She tells the story of one resident who was prescribed an antipsychotic several years earlier because he was resistant to care and would try to leave the building. As time went on, team members noticed he was not talking as much and spent more and more time just sitting in his wheelchair. Once his antipsychotic medication was reduced, everything changed. 

“As the weeks turned into months we started to see significant improvement,” says Shemilt. “He was walking again and smiling all the time.” He stopped resisting personal care and began helping the PSWs with a smile and a “thank you.”

Patel notes that antipsychotics can produce a chemical restraint in the body, reducing an individual’s ability to lift their hands, for example. When the medication is reduced or eliminated, the difference can be striking. Some residents were able to pick up a spoon for the first time in a year. Others began to wave to family members. 

“I honestly thought maybe we’d make a difference in a couple of the residents,” she says. “I was very surprised and happy to hear how significant the change was.” 

Shemilt and Patel both say the commitment of physicians and the frontline team has been critical to the initiative’s success. Education has also played an important role. Through the Living in My Today dementia educational program created by a partnership between Schlegel Villages and the Murray Alzheimer Research and Education Program at the University of Waterloo, team members are learning how to manage difficult behaviours by identifying the resident’s unmet need. 

“When a resident comes into the home, they’re in a different environment,” Patel says. “They may be a little agitated. It shouldn't be the norm to just start prescribing a medication. We need to do some behavioural management first.”

Other practices have also changed. Now each time residents are admitted or readmitted, Patel reviews whether they are on an antipsychotic. As soon as it is appropriate, the process of tapering the medication begins. 

With the success of the Humber Heights initiative, other Schlegel Villages homes are following suit. And Shemilt frequently receives emails from other long-term care facilities asking for information and advice. 

For both Shemilt and Patel, the results have far exceeded expectations. “As pharmacists, we are trained to give advice on health issues and make a significant difference in patient care,” says Patel. “In this instance, a small intervention led to a huge change. I feel like it really made a difference — and that is truly rewarding.”

The Villiage of Humber Heights was recently recognized by the Toronto Star for their efforts in reducing antipsychotic medications and improving resident quality of life. Click here to read this story.