Potentially inappropriate use of antipsychotic medications is an indicator calculated and maintained by the Canadian Institute for Health Information. It is calculated from LTC homes’ resident assessments and refers to the use of these medications for individuals without a diagnosis of schizophrenia, Huntington’s Disease, who are not experiencing hallucinations or delusions, and who are not at the end of life.

The 15% target includes the percentage of residents at the care home prescribed antipsychotics without an appropriate indication.

Antipsychotics may be appropriate when a resident:

• Has a diagnosis of schizophrenia or Huntington’s disease,
• Is experiencing hallucinations or delusions,
• Is receiving end-of-life care, or
• Shows severe behaviours (such as aggression or responsive behaviours) that pose a serious risk to themselves or others.

Decisions should involve the care team, the resident (when possible), and their family or substitute decision-maker, guided by clinical judgment and a thorough assessment of risks and benefits.

Some residents are prescribed antipsychotics for other conditions, such as:

• Bipolar disorder,
• Obsessive-compulsive disorder (OCD),
• Post-traumatic stress disorder (PTSD),
• Generalized anxiety disorder.

These uses may be clinically reasonable, but currently count as potentially inappropriate in the quality indicator. However, in 2026, bipolar disorder will be added to the list of appropriate indications.

Canada’s average rate of potentially inappropriate use is about 24.5%, which is nearly two and a half times higher than the United States (10%) and above rates in Australia (18%) and Sweden (15%).

The 15% target was developed by an expert panel through a consensus process. It provides a clear and achievable goal to encourage safer prescribing practices while allowing flexibility for appropriate clinical decisions.

The indicator captures potentially inappropriate use, which includes some clinically justifiable off-label or short-term uses. The 15% target allows room for careful clinical judgment and flexibility, where the benefits outweigh the risks.

Yes. The indicator uses risk adjustment to account for differences in resident populations and care settings, including homes with behavioural support units. This “levels the playing field” so homes are not unfairly compared when caring for residents with more complex needs.

Increases in the number of residents who were on antipsychotics when they were admitted to LTC have been observed. It speaks to the need for a whole-systems approach to appropriate antipsychotic use that extends beyond LTC into hospital and community settings. Having said that, LTC homes have an important role to play during the admission process, by:

• Assessing the medication’s appropriateness,
• Discussing with the care team and family,
• Deprescribing or adjusting medications safely as needed.

For these reasons, a resident’s first assessment is excluded from the indicator calculations.

The Canadian Institute for Health Information (CIHI) collects and reports data on potentially inappropriate antipsychotic use in LTC homes. CIHI provides homes with educational resources and support through partners like Healthcare Excellence Canada, including webinars to help staff accurately assess and code data.

Research so far does not show an increase in the use of benzodiazepines or other sedatives in homes with lower antipsychotic use. However, antidepressant use has risen, though it’s unclear if this is a substitute.

A more detailed review, including medications such as trazodone, is underway and will help understand if any medication substitutions are occurring.

Alternatives to antipsychotics include:

• Identifying and addressing triggers for behaviours, such as pain, hunger, or overstimulation,
  
• Using calming techniques like music therapy or creating comforting environments,
  
• Improving communication by using simple language and non-verbal cues,
  
• Providing meaningful activities to reduce boredom and agitation,
  
• Understanding the resident’s history, preferences, and strengths,
  

Educating and supporting staff and family caregivers on individualized care approaches.

Effective use of non-drug strategies requires:

• Staff training and education,
  
• Time to assess and monitor resident behaviours,
  
• Person-centred care plans tailored to individual needs,
  
• Supportive leadership and adequate resources,
  
• Involvement of family or substitute decision-makers where appropriate.

1. Review your most recent potentially inappropriate use of antipsychotics results with a group of staff and physicians in your home, including senior leaders. Is there a shared commitment to improving your results together? If so, move to step 2!
2. Establish a working group with those interested, ensure that at least one physician, nurse, pharmacist, personal care worker, and operational leader are participating.
3. Access available resources to identify a group of residents for your targeted interventions and evaluation. Examples include accessing Healthcare Excellence Canada’s Sparking Change program and, for those in Ontario, ISMP Canada’s program.