Use of antipsychotic drugs in the elderly living in the community up 26% in Ontario

The use of atypical antipsychotic drugs in the elderly living in the community has increased 26 per cent in the last five years. Researchers at the Institute for Clinical Evaluative Sciences (ICES) and St. Michael’s Hospital have found that the rise in use comes despite a systematic review of the evidence suggesting questionable benefit of these drugs when used in elderly patients with dementia.

Atypical antipsychotics are a newer generation of antipsychotics that are primarily approved for the treatment of patients with schizophrenia or bipolar disorder. However, the use of these drugs for the management of elderly patients with dementia to treat behavioural and psychological symptoms (such as psychosis, agitation, aggression or other symptoms) has been greatly debated over the past several years.

“While many physicians who we interviewed find these drugs to be useful tools when managing behavioural issues in elderly patients with dementia, our systematic review suggests that there are considerable risks associated with these products that may outweigh the benefits in many elderly patients when used inappropriately. Furthermore, the rising use of these medications and variation in their use across Ontario suggests that there may be a sizeable group of elderly patients who could be treated more safely and perhaps more effectively with other non-drug therapies,” says Tara Gomes, an author on the review and scientist with ICES.

However, the researchers add that any policies designed to address this issue, must also consider the limited options available to physicians in managing patients with difficult – and sometimes dangerous – behavioural issues related to dementia.  For this reason, one of the recommendations the researchers are making is the implementation of programs aimed at identifying patients who would benefit from alternate therapies, with the goal of reducing inappropriate use of antipsychotic drugs for the elderly with dementia.

In addition to the increase in use of atypical antipsychotics, there is a wide variation in their use across Local Health Integration Networks (LHINs) for the elderly living in the community and in long-term care homes. The review found:

• The Erie St. Clair LHIN (Sarnia/Windsor area) had among the highest rates of antipsychotic use in both long-term care homes and the community.
• The North Simcoe, Muskoka LHIN (Barrie/Orillia area) had the highest rate of community-based antipsychotic use.
• The North West LHIN (Thunder Bay/Kenora area) had the highest rate of antipsychotic use in long-term care homes, but the lowest rate of antipsychotic use in the community.
• The Mississauga LHIN had the lowest rate of antipsychotic use in long-term care homes.

“The variation is most notable between those living in long-term care homes where the rate of antipsychotic use is 328 per 1,000 elderly, compared to a rate of 22 per 1,000 elderly in the community. Although the rate of atypical antipsychotic use is higher in long-term care homes, two-thirds of all users live in the community, and approximately 40 per cent of those starting these drugs in the community end up moving to a long-term care home within one year,” adds Gomes, also a scientist at Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the scientific lead at Ontario Drug Policy Research Network (ODPRN).

The large drug class review of atypical antipsychotic use in the elderly was conducted by the ODPRN to provide policy recommendations for use of these drugs in Ontario. The drug class review found:

• Use of atypical antipsychotics in the elderly with dementia almost doubles the risk of mortality.
• There has been a 26 per cent increase in the use of atypical antipsychotics in the community-dwelling elderly during the last five years. Over this same period, there has been a 2 per cent decrease in use of these products in LTC homes.
• The rate of use in long-term care homes is 328 per 1,000 elderly, compared to 22 per 1,000 elderly in the community.
• Although the rate of use is higher in long-term care homes, two-thirds of all users live in the community (72,488 in the community versus 32,580 in long-term care homes in 2013).
• Nearly 40 per cent of elderly patients in the community who are started on atypical antipsychotics will end up in a long-term care home by the end of the year.

The drug class review included a qualitative analysis of perspectives of patients and healthcare providers, an environmental scan of how these drugs are covered in other jurisdictions, a pharmacoepidemiologic study of use of these medications across Canada and how funding status impacted accessibility and potential risks, a systematic review of evidence for efficacy/safety and an economic analysis of budget impact of potential drug reimbursement options.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

For the latest ICES news, follow us on Twitter: @ICESOntario

For the latest from the Ontario Drug Policy Research Network, follow us on Twitter: @ODPRN_Research

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future healthcare professionals in more than 23 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, and care of the homeless are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Center, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

FOR FURTHER INFORMATION PLEASE CONTACT:

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• Leslie Shepherd
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