Rising Rates 


Antipsychotic Use in Canada's LTC Homes

Antipsychotic use in people who are not experiencing psychosis is generally regarded as an inappropriate approach to the care of older adults in long-term care (LTC). Yet, these powerful medications have become commonplace in Canadian LTC homes, often as the first choice for managing behaviours associated with dementia such as aggression and resisting care—despite Canadian guidelines cautioning against their frequent use for these symptoms.

Antipsychotic medications carry significant risks, including a higher likelihood of strokes, falls, fractures, and even death. Prescribing them without addressing the root causes of these behaviours or exploring non-drug alternatives raises serious questions about the safety and quality of care for one of Canada’s most vulnerable populations.

For over a decade, the Canadian Institute for Health Information (CIHI) has been reporting on the rates of potentially inappropriate use of antipsychotics in LTC settings in Canada. The latest data, for the 2023-2024 fiscal year, is presented here for the first time along with extensive analysis of trends and variations across Canada. The data has been risk-adjusted so that it’s comparable across LTC homes.

The data and analysis below was prepared by subgroup members of the Appropriate Use Coalition, using CIHI data.

A Decade of Tackling Antipsychotics

The use of antipsychotics in Canadian LTC homes over the past decade can be observed in distinct phases: pre- and post-pandemic. In the years prior to COVID-19, steady progress had been made to curb their use. The percentage of LTC residents on antipsychotics without a diagnosis of psychosis had decreased from 27.2% to 20.2% between 2014-2015 and 2019-2020 due to significant efforts to address the behavioural and psychological symptoms of dementia by other means. Since the onset of COVID-19, however, antipsychotic use has been on the rise, climbing to 24.5% in the most recent year, and undoing much of the progress of the past decade.

For context, the national rate in the United States is 10%. In Australia and Sweden, it is 18% and 15%, respectively.

The reasons for this rise are not entirely clear, but the pandemic likely exacerbated the conditions for their use. For example, staffing shortages and pressures on infection control programs at the height of the pandemic could have resulted in LTC homes turning to antipsychotics to help manage residents. One Canadian study even suggested that antipsychotics may have been prescribed as a preemptive measure since the prevalence of behavioural symptoms did not actually increase during the pandemic period.

Regardless of the reasons, the fact that antipsychotic use remains elevated well after the height of the COVID-19 emergency suggests that perhaps a new normal has been established, with one in four LTC residents on antipsychotics potentially inappropriately.

Variation Across Canada

Use of antipsychotics in LTC varies significantly across provinces and territories. While the overall rate for Canada was 24.5% in 2023-2024, most provinces and territories, with the exception of Alberta and Ontario, were well above the national rate.

Regardless of where they stood in 2023-2024, every reporting province and territory’s rate rose by at least 2% since the start of the pandemic. The steepest rise was in Newfoundland and Labrador, where the proportion of LTC residents on antipsychotics rose from 23.1% to 31.8%, an absolute increase of 8.7%. Even in Ontario and Alberta, which have the lowest rates in the country, usage increased by 2.2% and 4.4% since the start of the pandemic, respectively.

Variation Across LTC Homes

Variation is most striking at the level of individual LTC homes. Among the 1,500 sites that reported antipsychotic use data in 2023-2024, rates ranged from zero to 86.3%, with the median being 23.6%.

The 10th percentile rate was 10.5%. In other words, 150 homes had rates of antipsychotic use at or below 10.5 percent. Conversely, the 90th percentile rate was 40.8%, meaning 150 homes had rates at or exceeding 40.8%.

At the provincial and territorial level, variation is greatest in New Brunswick and lowest in Ontario. This is all relative, of course, since even in Ontario rates varied widely, from zero to 56.9% among the more than 600 LTC homes in the province.

The 2023-2024 rate of potentially inappropriate use of antipsychotics for all 1,500 LTC homes for which data is available in Canada can be found in the following searchable table.

Use of Physical Restraints

Physical restraints are sometimes used to manage behaviours among LTC residents. As such, there is a concern that any emphasis on reducing antipsychotic use could lead to a corresponding increase in restraint use as a substitute. However, physical restraints are not an acceptable alternative, as their use can lead to significant physical and psychological distress for the individual.

Prior to the start of the COVID-19 pandemic, restraint use was on a steady decline in Canada, mirroring the trend in antipsychotic use—a good sign that LTC homes were finding appropriate ways to manage behaviours among residents. At the height of the pandemic, restraint use spiked but it has since tapered off to 4.9%, unlike the situation with antipsychotics.

Provinces and territories with lower rates of antipsychotic use, namely Alberta and Ontario, also have lower rates of restraint use. Conversely, those with higher rates of antipsychotic use also had higher rates of restraint use.

Getting Back on Course

Antipsychotic use is heading in the wrong direction in Canada.

The good news is we know how to decrease their inappropriate use. Many provinces and territories have been successful in doing so in the past. At least until the start of the pandemic, LTC homes were making progress through a mix of large-scale and local quality improvement efforts. However, the LTC sector today is also facing considerable staffing shortages and high turnovers—systemic problems that make it more challenging for quality improvement than in the past.

For Canada to get back on course, there is a need for a coordinated response, one that involves not just LTC homes themselves, but also system actors who play a role in shaping the conditions of the sector. There is also the need for a clearer goal for where Canada should be, and what residents and their family can consistently expect regardless of which LTC home they set foot in. The creation of the recently-launched Appropriate Use Coalition, and its work to set a national target for appropriate use of antipsychotics in LTC are good starting points.

About the Coalition

The Appropriate Use Coalition consists of 11 organizations that are working collectively to improve the appropriate prescribing and use of medications in Canada.

The Coalition’s Long-Term Care Subgroup, responsible for this report, is working to address the specific issue of appropriate use of antipsychotics in LTC including the development of quality improvement programs and critical tools and resources.

Appropriate Use Coalition – Long-Term Care Subgroup Members:

*Secretarial support is provided by Canada’s Drug Agency

National Target

​An expert panel has been convened by Canada’s Drug Agency in collaboration with Choosing Wisely Canada to provide guidance on the appropriate use of antipsychotics in LTC. Using a modified Delphi process, experts will deliberate on evidence from a number of sources to produce consensus statements for a national target rate for antipsychotic use in Canada’s LTC sector. The national target is scheduled for release in mid-2025.

To learn more about the work of the expert panel or submit feedback: https://www.cda-amc.ca/appropriate-use-antipsychotics-long-term-care