Off-label use of antipsychotics in nursing home patients not tracked in rural Manitoba

A gap in Manitoba’s reporting system means the majority of nursing homes in the province cannot track the number of residents receiving antipsychotics without a diagnosis.

Nearly a quarter of residents in Winnipeg’s 38 nursing homes are receiving these powerful drugs without being shown to need them clinically, a CBC survey has found.

But the extent of the problem in the other 87 homes across the province is unknown, as data is not collected and homes do not report those numbers publicly.

Melissa Marchischuk’s 87-year-old mother has dementia and lives in a Minnedosa nursing home.

For the past five years, her mother has been on the antipsychotic risperidone. She said her mother had not been diagnosed with a mental illness that the drug is supposed to treat.

“I think they’re just trying to put them to sleep,” Marchischuk told CBC News.

“But risperidone is not the right way to put them to sleep or calm them down.”

During the periods when her 87-year-old mother was not taking risperidone, Melissa Marchischuk says her dementia symptoms seemed to improve. (Simone Hogan/Shutterstock)

Antipsychotics like risperidone are used to treat a variety of mental health conditions, but primarily for those that include psychotic symptoms, such as schizophrenia or bipolar disorder.

Risperidone can be used in the short term to treat severe dementias of the Alzheimer type, according to Health Canada.

Marchischuk said his mother could no longer walk and was in a reclining wheelchair. She needs to be fed and watered, and she doesn’t always make sense when she speaks.

But on occasions when she had to go to the hospital and was taken off all her medication, Marchischuk said her mother’s cognitive abilities improved.

“Once she gets better, she goes back to risperidone and all is lost,” Marchischuk said.

“When mum was on risperidone she was worse. Like the fears, and whatever the mind is going through with dementia, I felt worse.

The Winnipeg Regional Health Authority monitors residents who receive the medications without a diagnosis and reports them to the Canadian Institute for Health Information.

The Institute publish these figures every yearallowing Winnipeggers to see how each nursing home is performing and which prescribes the most off-label antipsychotics.

Provinces such as Alberta, British Columbia and Ontario also report these figures to the institute, allowing for a comprehensive analysis of antipsychotic use in nursing homes across the province.

According to a map from the Canadian Institute for Health Information, Manitoba has no assessment of “potentially inappropriate” use of antipsychotics in long-term care homes. (CIHI)

The lack of data in Manitoba personal care homes outside of Winnipeg is problematic, says Dr. Samir Sinha, director of geriatrics at Sinai Health and University Health Network in Toronto.

“They might perform a lot better than Winnipeg. They might perform a lot worse. But when you don’t actually have data, you can’t really monitor what you don’t actually measure,” Sinha said.

Jon Gerrard, Manitoba Liberal Party health critic, agrees.

“People in rural areas [nursing] households are not second-class citizens. They deserve to have the same type of oversight and standards that the people of Winnipeg have,” he said.

Health regions outside of Winnipeg were able to provide an aggregate figure to show the total percentage of residents on antipsychotics. The figures show that the rates were much higher outside of Winnipeg.

The number does not separate those who are diagnosed with an illness that might require the drug from those who receive off-label drugs to treat dementia or control behavior.

They also don’t provide a breakdown of the percentage for each care home.

Percentage of residents on antipsychotics in July/August 2022:

  • Interlake East Regional Health Authority – 35.7%
  • Northern Health Region – 33.2%
  • Prairie Mountain Health – 31.6%
  • Southern Health – 29.5%
  • Winnipeg Regional Health Authority – 28.4%

Sinha says the public and medical professionals need to know all the information surrounding the use of these drugs so they can ask the right questions.

“In those settings where they have higher rates of prescribing antipsychotics, are there higher rates of diagnosed psychosis, for example, that would require those drugs?” he said.

“Is this a justifiable variation or is there something that tells us there is an opportunity to improve the quality of care provided?” He asked.

“[Or] another factor that may need to be better understood? »

Drug use monitored every 3 months: health regions

All four health regions outside of Winnipeg provided statements on how they monitor antipsychotic use in the home.

All told CBC News, in accordance with Manitoba Health policy, individual medication reviews are done every three months for each resident.

Often, the use of these drugs begins before the resident is admitted to a home, so getting the resident out requires a “structured approach,” a Prairie Mountain Health spokesperson said.

During the three-month medication reviews, residents are reassessed and “opportunities for dose reduction or discontinuation” are explored, according to a spokesperson for the Interlake-Eastern Regional Health Authority.

A woman in a brightly colored dress speaks into a microphone.
A spokesperson for Manitoba Health Minister Audrey Gordon declined to comment on whether the government would commit to changing the reporting structure of rural health regions on antipsychotic use in nursing homes. (CTV News Group)

When asked on Wednesday whether they would consider getting rural care homes to start tracking this, Health Minister Audrey Gordon said it was up to “clinicians”.

“If families feel there is a gap in the data collected or in the tracking of information, we can certainly inform the leaders of the region and the leaders of Shared Health,” she said.

Draper Houston, the minister’s spokesman, declined to comment on whether the government would commit to changing the reporting structure for rural health regions.

Instead, he made a brief statement that “all regional health authorities routinely review medications with patients.”

Marchischuk says it’s time for the rest of Manitoba to catch up to Winnipeg when it comes to reporting the use of these drugs.

“It has to be followed,” she said.

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