Antipsychotics and Dementia

There are currently 500,000 older adults with dementia in Canada. The Centre for Effective Practice (CEP) developed three tools to help promote a better understanding of best practices for assessing and managing patients with dementia, with a particular focus on the use of antipsychotics. The content is similar in each Tool, with modifications to meet the needs of these audiences:

  • Primary Care Edition — for primary care providers.
  • Long-Term Care (LTC) Edition — for providers, administrators, caregivers, and interested residents and families in Long-Term Care Homes as part CEP’s Academic Detailing Service.
  • Resident and Caregiver Edition — specifically for families, caregivers and residents of Long-Term Care Homes.

Question #1: What BPSD symptom cluster is best described by the following symptoms: dressing/undressing; pacing; restless/anxious?

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Question #2: When using the P.I.E.C.E.S. (TM) RISKS mnemonic to assess risks to patient and others, what does RISKS stand for?

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Tool

Primary care edition:
UseofAntipsychotics_PrimaryCare2016 Download

Long-term care edition:
UseofAntipsychotics_LTC2016 Download

Resident, family and caregiver guide:
caregivercover-791x1024 Download

The Centre for Effective Practice (CEP) developed three tools to help promote a better understanding of best practices for assessing and managing patients with dementia, with a particular focus on the use of antipsychotics. Each tool contains information to help providers, caregivers, family members and Long-Term Care home residents:

  • Discuss and document behavioural and psychological symptoms of dementia.
  • Use non-drug therapy as an important part of management, regardless of whether drug therapy is initiated.
  • Weigh the benefits and harms of using antipsychotics.
  • Understand when and how to initiate drug therapy for appropriate symptom clusters.Each edition of the tool includes references to relevant existing tools, strategies and services.
  • The LTC edition is used as a resource for CEP’s Academic Detailing Service.

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Project Overview

There are currently 500,000 older adults with dementia in Canada. That number is expected to rise to 1.1 million in the next 30 years.

People with dementia have trouble with memory, thinking, problem-solving and using language. They may exhibit more difficult behaviours, including extreme agitation, extreme aggression and psychosis. These challenging behaviours are a normal part of the course of dementia but they can be upsetting for the patient and others. It is important for providers, caregivers and family members to work together to identify triggers and try manage these behaviours with individualized, non-drug strategies.

When there is severe aggression or psychosis that puts someone at risk, antipsychotic medications may help. These medications can cause some side effects and may even increase risk of stroke or death so it’s important to only use them when needed. The Centre for Effective Practice developed three Tools to help providers, caregivers, family members and Long-Term Care home residents assess and manage patients with dementia, with a particular focus on the use of antipsychotics.

Each of the three editions contains information about ten basic steps to managing dementia:

  1. Describe and identify the symptom or behaviours
  2. Document behaviour
  3. Identify cause(s) of symptoms or behaviours
  4. Engage caregivers and family
  5. Manage symptom(s) with individualized non-drug therapy
  6. Consider drug therapy
  7. Monitor and document non-drug and drug therapy for effectiveness and adverse effects
  8. Follow-up
  9. Consider deprescribing drug therapy when appropriate
  10. Continue to individualize non-drug approachesDevelopment Process

Primary Care Tool

The Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Primary Care 1st Edition

The Primary Care Edition of the Tool is one of several developed as part of the multi-year Knowledge Translation in Primary Care Initiative. The initiative is a collaboration between Centre for Effective Practice (CEP), the Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative will support primary care providers with a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, CEP conducted a Primary Care Needs Assessment to determine topics of interest to primary care providers. In this survey 88% of providers identified the need to have more clinical tools to help with care of the elderly.

The Primary Care Edition of the Tool was developed in parallel with the Long-Term Care and Resident and Caregiver Editions using CEP’s integrated knowledge translation development methods. CEP ensures that health care providers are engaged throughout the tool development process, using a User Centered Design methodology to test the usability of tools from a provider perspective. CEP’s Academic Detailing Service Team, with clinical leadership from Dr. Sid Feldman developed, the Primary Care Edition

Long-Term Care Tool

The Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Long-Term Care (LTC) 2nd Edition

The Long-Term Care Edition of the Tool was developed as part of Centre for Effective Practice’s Academic Detailing Service for LTC homes. It was designed to help providers engage in meaningful discussions with the Academic Detailing Team about the management of dementia and the use of antipsychotic medications. As always, efforts must be made to individualize any treatment decisions for the resident, with consideration for caregivers, family as well as LTC staff.

CEP’s Academic Detailing Service Team, with clinical leadership from Dr. Sid Feldman and Dr. Andrea Moser, developed this edition of the tool. Health care providers and other relevant stakeholders were engaged throughout the tool development process, using a User Centered Design methodology to test the usability of tools from a provider perspective. This edition was funded by the Province of Ontario as part of CEP’s Appropriate Prescribing Demonstration Project.

Resident and Caregiver Tool

Using Antipsychotic Medications to Help People with Behavioural Symptoms in Dementia

The Resident and Caregiver Edition of the Tool is being developed as part of Centre for Effective Practice’s Academic Detailing Service for LTC homes. The content was adapted from the Long-Term Care Edition of the Tool under the clinical leadership of Academic Detailer, Kristin Ferguson. Residents of LTC homes and family members were engaged throughout the tool development process, using a User Centered Design methodology to test the usability of tools.

Meet the Team

The Antipsychotics in Dementia Tools were developed with input and review from the Centre for Effective Practice’s Academic Detailing Service Team, with support from clinical leads. Health care providers, residents of Long-Term Care homes, family members and other stakeholders were also engaged throughout the development of tools.

Clinical Leads

Dr. Sid Feldman
Dr. Sid Feldman – Primary Care Edition & Long-Term Care Edition

Dr. Sid Feldman is a community family physician affiliated with the North York Family Health Team. He also works as attending physician in the Toronto Central LHIN Behaviour Support Unit at Baycrest for residents with behavioural symptoms of dementia. His academic and administrative roles at Baycrest include Medical Director, Home for the Aged, Executive Medical Director Residential and Aging at Home Program and Chief, Family and Community Medicine. He is an Associate Professor and Coordinator, Care of the Elderly Program in the Department of Family and Community Medicine, University of Toronto and serves as the Ontario representative on the CFPC Health Care of the Elderly Program Committee.

Dr. Andrea Moser
Dr. Andrea Moser – Long-Term Care Edition

Dr. Andrea Moser is a family physician with a clinical practice is in long term care and home visits for housebound frail seniors at Baycrest Health Services. She is an Assistant Professor in the Department of Family and Community Medicine, University of Toronto, Associate Medical Director, Apotex Nursing Home at Baycrest and is a Certified Medical Director through the American Medical Directors Association. At Baycrest she is also co-chair of the Apotex Quality Subcommittee and a member of the Quality Steering Committee. She also has extensive experience in rural practice. Dr. Moser has a particular interest in dementia care and is involved with the Behavioural Supports Ontario (BSO) program through her clinical work at Baycrest on the Transitional Behavioural Support Unit and the LTC Behavioural Support Outreach Team and is the BSO primary care lead for Central LHIN. Dr. Moser is the chair of the OMA Section of Care of the Elderly and LTC, and a member of the Board of Directors of the Long Term Care Medical Directors Association of Canada.

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Kristin Ferguson – Resident and Caregiver Edition

Kristin Ferguson is an experienced community pharmacist. She has managed a community pharmacy for more than seven years while becoming involved in the non-profit healthcare sector. Kristin completed her pharmacy degree at the University of Toronto and also received her Bachelor of Health Science from the University of Western Ontario with an interest in health promotion in a rural setting.   As a volunteer, Kristin has worked with the Port Hope Community Health Centre for many years and now sits on the board of directors.   This reflects her commitment to giving back to her community.   Kristin enjoys the outdoors and also spends time canning and preserving with produce from her farm.

Supporting Material

Here are some additional resources and sources of information. These supporting materials are hosted by external organizations, and as such the accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

For Primary Care Practices

This inventory for primary care providers includes useful clinical aids and patient/family material. This list includes direct links (where available) to tools or materials, based on an environmental scan, appraisal by clinical leads, and focus groups with primary care providers.

For Long-Term Care Homes

This inventory for long-term care providers includes useful clinical aids and resident/family material. The list includes direct links (where available) to tools or materials that are directly referenced in the detailing guide and/or have been reviewed by CEP and identified as important material in supporting the uptake/adoption of the detailing guide. It includes a brief description of the tool, with full references available as indicated on page 8. The inventory is a comprehensive but not exhaustive list based on an environmental scan, appraisal by clinical leads, and focus groups with long-term care providers.

For Residents and Caregivers

Copyright & Disclaimer

CEP fully supports the use of The Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Primary Care  Edition; Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Long-Term Care (LTC 2nd Edition) and Using Antipsychotic Medications to Help People with Behavioural Symptoms in Dementia: Resident and Caregiver Tool by providers, educators, decision-makers and others. Please read the following information prior to use of the Tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative Commons The Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Primary Care  Edition; Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Long-Term Care (LTC 2nd Edition) and Using Antipsychotic Medications to Help People with Behavioural Symptoms in Dementia: Resident and Caregiver Tool are products of the Centre for Effective Practice. Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citations.  Use of these Tools for commercial purposes or any modifications of the Tools are subject to charge and use must be negotiated with Centre for Effective Practice (Email: [email protected]).

For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the Tool.

Please use these citations when referencing the Tools:

Reprinted with Permission from Centre for Effective Practice. (April 2016). Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Primary Care Edition.

Reprinted with Permission from Centre for Effective Practice. (April 2016). Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Long-Term Care (LTC 2nd Edition).

Reprinted with Permission from Centre for Effective Practice. (April 2016). Using Antipsychotic Medications to Help People with Behavioural Symptoms in Dementia: Resident and Caregiver Tool.

Disclaimer

The Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Primary Care  Edition; Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide: Long-Term Care (LTC 2nd Edition) and Using Antipsychotic Medications to Help People with Behavioural Symptoms in Dementia: Resident and Caregiver Tool (the “Tools”) each contain links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations. These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Third Party Resource(s).

These Tools were developed for licensed health care professionals in Ontario as guides only and do not constitute medical or other professional advice. Primary care providers and other health care professionals are required to exercise their own clinical judgment in using these Tools.

Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to these Tools, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through these Tools; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of these Tools by any individual including, but not limited to, primary care providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of these Tools, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.