Potentially inappropriate use of antipsychotic medications 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 end of life.

Antipsychotic medications carry significant risks, including a higher likelihood of strokes, falls, fractures, pneumonia, blood clots, and even death.

Antipsychotics may be used on a short-term basis in some situations where behaviours like severe aggression or responsive behaviours pose a significant serious risk to the individual or others. These medications should be typically considered only in true emergencies where significant harm is likely without treatment, or in less urgent circumstances, after other non-pharmacological and less risky interventions have been tried and found ineffective, when the benefits outweigh the risks, and only with informed consent of the individual/substitute decision maker.

Behavioural approaches may include:

• Identifying and addressing triggers for behaviours (e.g., pain, hunger, or overstimulation).
• Using calming and consistent techniques, such as music therapy or creating a comforting environment.
• Enhancing communication, such as using non-verbal cues or simplifying instructions.
• Providing meaningful activities to reduce boredom and agitation.
• Understanding the unmet needs of the individual, along with their routine, history, strengths and preferences.
• Educating staff and family caregivers in individualized approaches to care.

The planned process of reducing or stopping antipsychotics that may no longer be of benefit or may be causing harm (i.e. deprescribing) might benefit residents, family, and care providers in several ways:

• Improved quality of life
• Improved independence, mobility, alertness
• Improved connection with family
• Increased ability to socialize and participate in activities

Implementing behavioural approaches may require:

• Training staff.
• Adequate time to assess and monitor individual behaviours.
• A person-centred care plan tailored to the individual’s needs and focusing on their strengths and preferences.
• Supportive leadership and resources to ensure staff have the tools needed for these interventions.
• Family involvement, where appropriate.

Inappropriate antipsychotic use may be influenced by:

• A culture of prescribing over person-centred care practices.
• Lack of training in person-centred approaches.
• Time pressures that make non-pharmacological interventions more effort to implement.
• Misinterpreting unmet needs to be psychiatric symptoms instead.
• Pressure from families or care teams to manage behaviours quickly.
• Reluctance to discontinue antipsychotic medications that were prescribed before a resident’s admission to LTC or by a specialist.

While staff shortages can be a challenge for any quality improvement strategy, relying on antipsychotic medications as a substitute for adequate staffing or training is not best practice. Addressing staffing issues and providing proper training are critical to delivering high-quality care and minimizing inappropriate medication use.

Behavioural units may have higher rates of antipsychotic prescriptions due to the complexity of managing more responsive behaviours. The “potentially inappropriate antipsychotic medication” indicator specifically measures instances where these medications are used without a diagnosis requiring this drug class.

The goal is not to eliminate antipsychotic use entirely but to ensure they are prescribed appropriately. For example, antipsychotics may be indicated for individuals with bipolar disorder, major depressive disorder, and the treatment of aggression in people with severe dementia. In complex cases, decisions should be guided by clinical judgment, a thorough risk-benefit assessment, and input from the care team, family, and the individual when possible.

As the quality indicator in long-term care measures potentially inappropriate rather than inappropriate use, some residents receiving antipsychotics appropriately may still be captured in the indicator. Off-label but clinically reasonable use, such as for obsessive-compulsive disorder, post-traumatic stress disorder, or generalized anxiety disorder, may be categorized as potentially inappropriate. That’s why the target isn’t zero—it allows flexibility for cases where the benefits outweigh the risks.

The potentially inappropriate antipsychotic use quality indicator is risk adjusted for the purpose of fair comparison. The risk-adjustment is to account for individual and home-level differences. This means that homes with a higher number of complex residents—such as those experiencing motor agitation, moderate to impaired decision-making issues, long-term memory problems, a combination of Alzheimer’s disease and other dementia, as well as younger residents (under the age of 65)—are reflected in the adjustment.

The indicator “potentially inappropriate antipsychotic use in LTC” was developed by interRAI researchers including international experts. The interRAI researchers continually conduct and publish research on this and other quality indicators, ensuring validity and relevance of their measures.

The “potentially inappropriate use of antipsychotic” indicator has been calculated at the Canadian Institute for Health Information (CIHI) for more than a decade. Statistical analysis of the longitudinal data from jurisdictions who have transitioned from the MDS 2.0 to the LTCF have been used to inform the comparability of this indicator. Based on statistical analysis, consultations with interRAI and clinical expertise, the rate calculated with the LTCF is comparable and equivalent to that calculated with the MDS 2.0. There is no evidence to suggest that achieving the target rate or the yearly decrease in the indicator rate will be affected by which assessment is being used. As CIHI continues to receive LTCF data from across Canada, comparability analysis will continue.

1. Review your most recent potentially inappropriate use of antipsychotic 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.