drugging the elderly: how much is too much?

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The prescription drug problem in the province of Quebec, particularly with respect to elderly people, which I first blogged about here and which is highlighted in the video below, is tragically out of hand.

A 2015 study by McGill University researchers found that “nearly 12 per cent of Quebec physicians’ prescriptions were “off-label” and of these, more than 80 per cent have no scientific evidence for non-approved use. A Montreal Gazette article on the study quoted researchers as saying “the most common medications prescribed off-label are those affecting the central nervous system specifically: antidepressants, antipsychotics and anticonvulsants. Patients taking these kind of medications reported various unwanted effects including weight gain, nausea, abdominal pain, grogginess, dizziness, loss of balance and confusion.”

My mother, who lived with dementia of the Alzheimer type, experienced all of the side effects above as a result of being given antipsychotics, which are prescribed inappropriately at an alarmingly high rate to thousands of Quebec seniors who live with Alzheimer disease. Philippe Voyer, researcher, nursing professor and supervisor of the Mentorship Clinique at the Quebec Centre for Excellence in Aging describes the levels at which antipsychotics are prescribed to elderly people who live with Alzheimer disease as “abusive.”

This is not a new issue. One of the lead researchers of the 2015 study above did a similar study in 1990, which concluded that:

“The prevalence of questionable high-risk prescribing [in Quebec], especially of psychotropic drugs, is substantial among elderly people. This may be a potentially important and avoidable risk factor for drug-related illness in elderly people.”

Things seem to have worsened since then. The 1990 and 2015 research findings are echoed in the Government of Quebec’s 2015 report “Prescription Drugs: Optimizing Costs and Use for the Benefit of the Patient and the Sustainability of the System,” which states:

“The increased use of some prescription drugs is questioned, especially in some population groups, including the elderly and children.”

Furthermore, according to a report by the Ontario Drug Policy Research Network, the use of antipsychotics among the elderly in Quebec, which was already the highest in Canada in 2009, increased by 31% over five years. Here’s what that looks like:

This is a costly practice. More important than the financial burden of this type of drug abuse, however, is the human cost, particularly in children and the elderly, and especially for extremely vulnerable elders who live with dementia, and are thus unable to speak for themselves. Far too many are inappropriately prescribed antipsychotic medications when instead they should be more humanely treated with kindness, compassion and understanding.

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9 Comments

  1. To “husband with dementia”, Believe me I feel your pain everyday when I see the same type of problems in my facility. Its hard on families, staff and other residents. Our state looks hard at antipsychotic use. Do they have a diagnosis that supports use of antipsychotics, is the biggest question. We do use them off label but at a price because there are a lot of side effects with antipsychotic use and the elderly. That is why there are regulations on their use. Sometimes, you are right that’s the only recourse we have. However we should all try to use non pharmacological interventions before putting anyone on antipsychotics.

  2. My husband is in a dementia care facility. He has Alzheimer’s Disease and vascular dementia with violent aggression. Unlike most people with dementia, he is physically healthy, agile and strong. He is a distance runner: he is a flight risk. Already he has escaped 3 times. He needs effective management of his symptoms for his safety and the safety of those around him. His caregivers and the other residents of his care home are at risk. It is not acceptable to say sometimes there are no answers. Answers evolve. Antipsychotic drugs relieve the progressive fearful state of his condition. He cannot come home: his violence is very real. The antipsychotic meds are the only — at this time — recourse we have to treat him. We attempt daily a delicate balancing of an insidious progressive disease. And we do this at a mighty high price for his care which will sap our retirement savings.

    • Dear Ellen,

      Thanks for your comment. I understand there are some circumstances in which there is no recourse but to medicate people, and perhaps your husband’s case is one of them. However, I would also suggest that the number of cases where antipsychotics are the only answer are a fraction of the cases in which they are actually used. Most often caregivers, including family members in the home, and care workers in facilities, do not have the knowledge, training and skills required to avert, defuse and de-escalate potentially violent situations. They may think they do, they may say the do, but in fact they don’t.

      My mother was medicated into a catatonic state every day for almost four years ABSOLUTELY NEEDLESSLY. The facility staff said the was “aggressive,” and “violent” and a danger to herself and others. But the problem was not her, it was them. It was the environment and the way she was treated that caused her to react in ways that were problematic for them. I know this to be true because in the entire year I lived with her, she was never violent with me with one exception which you can hear at this link: http://myalzheimersstory.com/2016/12/08/5-surefire-ways-to-stop-anger-and-aggression-in-people-who-live-with-alzheimers-disease-in-the-mid-and-later-stages/ That one occasion was not her fault, it was mine. Once I learned what I was doing that was not effective and I changed my behaviour, her behaviour also changed. While she was in the facility, where I visited for several hours every day for the entire time she was there, she was NEVER violent with me. She was also NEVER violent with one-on-one companions who were with several hours several times a week – on the contrary, the was as calm as a kitten.

      Also, what Anonymous says is true. There are side effects, and the side effects are often the very behaviours the drugs are given to alleviate. A recent Canadian project that reduced and eliminated the use of antipsychotics in care homes by 54%, reduced aggressive behaviour at the same time. You can read more here: http://myalzheimersstory.com/2016/08/04/what-happens-when-care-homes-stop-giving-antipsychotics-to-elderly-people-with-dementia/

      If your husband has been diagnosed with psychosis, then antipsychotics may be appropriate, and as I said, perhaps in your case they are required. However, as I also said, they are not required in the vast majority of cases which is being proven by the worldwide reductions we are now beginning to see, except in the case of the province of Quebec in which I live.

      Here is a list of behaviours that antipsychotics art known NOT to have an impact on:

      Behaviours with limited/no known benefit from antipsychotic use: The following
      responsive behaviours are known NOT to be improved by the use of antipsychotic medications:
       Wandering / exit seeking
       Unsociability
       Poor self-care
       Impaired memory
       Fidgeting or nervousness
       Inappropriate voiding/elimination
       Restlessness or pacing
       Indifference to surroundings
       Repetitive vocalizations: calling, screaming
       Repetitive actions such as clapping
       Inappropriate dressing/undressing
       Pushing wheel-chair bound residents
       Eating inedible objects
       Hoarding / hiding items

      More information here: http://www.albertahealthservices.ca/assets/about/scn/ahs-scn-srs-aua-prescribing-antipsychotic.pdf

      I’m so sorry this disease is having such a devastating effect on you and your husband. My heart goes out to you.

      Susan

  3. Hi, Although I understand what you are saying and for the most part agree. As a nursing home administrator I try daily to treat my residents and my employees the way I would want to be treated. The biggest challenge is many times we get patients that are either violent, self harming, exhibit behaviors that may harm themselves or others. While we cant use any type of restraint whether physical or pharmacological, its difficult to find ways to care for theses patients. We have to keep all of our residents safe or free from harm. All the love, care and treatment will not fix these problems. So just the other side of the coin, we do the best we can, with the resources we have. Drugs definitely arent the answer. Many times they do more harm then good. We dont have the answers we just do what works.

    • Carol, Thanks for your comment and I’m glad you treat others as you would want to be treated. I feel that often people simply don’t have the skills or training to 1) understand what lies behind behaviour, and 2) even if they do understand, they don’t have the skills or training to address the issues in ways that are useful and nonproblematic. I agree that sometimes no matter what you do there’s no way to solve the problem. However, I would suggest that that those instances are far less often the case than people believe. I would agree with you that drugs are definitely not the answer and that they often do more harm than good. And sometimes there are no answers.

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