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In this episode, we speak with family and long-term care physician Sid Feldman about the KevinMD article “Antipsychotic use has been rising in long-term care homes, but we can do something about it.” Sid shares how prescribing rates have surged to 24 percent in Canada, highlights the serious risks of antipsychotic medications, and emphasizes the importance of person-centered strategies. He also provides actionable ideas for addressing pain, encouraging staff education, and refocusing on holistic approaches that promote well-being for older adults living in long-term care.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Sid Feldman. He’s a family and long-term care physician, and he co-wrote the KevinMD article, “Antipsychotic use has been rising in long-term care homes, but we can do something about it.” Sid, welcome to the show.
Sid Feldman: Thanks so much, Kevin. Great to be here.
Kevin Pho: All right, so tell us what this particular article is about.
Sid Feldman: So we’ve noticed a trend in Canada that, in long-term care, before the COVID-19 pandemic, we had been doing a really good job of getting our rates down. We were down to about 20 percent or so, and then through the course of the pandemic in long-term care—it was really all hands on deck to try and deal with the crisis of the pandemic in the nursing home environment. Unfortunately, what we found is that the rate of antipsychotic use in our long-term care homes has crept up to around 24 percent. We just wanted to call attention to that so that we can all collectively make an effort to get back on track with this particular measure.
Kevin Pho: All right. So for those who aren’t versed with antipsychotics in the long-term care facility, give us some context in terms of when they’re typically used, what medicines are used—just some background before we explore further.
Sid Feldman: For sure. First of all, these are incredibly useful medications, especially for residents or patients who have serious mental illness. For those with schizophrenia who have psychosis, for people with severe depression that requires augmentation, for people with Huntington’s disease, these medications can make the difference between a life of purpose, meaning, and joy versus a life that is really quite despairing. So I want to start by saying these are important drugs to have in our armamentarium for the right patient.
Where we get more concerned, though, is the application of antipsychotic medications for patients who have dementia and behavioral symptoms of dementia. Behavioral symptoms of dementia go by many names—neuropsychiatric symptoms, behavioral and psychological symptoms of dementia, or “responsive behaviors.” In any case, there’s a trend toward the use of antipsychotic medications to treat people with these conditions, and we’re probably overusing them compared to the number of folks who really need them.
There are absolutely good randomized controlled trials showing that these drugs are effective for conditions like severe aggression, but they’re also being used for people who may have more moderate aggression, or they’re being used for too long a period of time, or perhaps there are other nonpharmacological strategies we can be using that would manage the behaviors without needing these very powerful medications.
Kevin Pho: In particular, examples of these medicines: are we talking about Haloperidol, Zyprexa, perhaps?
Sid Feldman: Exactly. Most commonly, we’d be using some of the atypicals—risperidone, olanzapine, aripiprazole, brexpiprazole, quetiapine. Those would be the ones we commonly use. Here in Canada, we have an indication for risperidone and for brexpiprazole. There are others in the literature that have some evidence behind them as well.
Kevin Pho: And tell us about some of the concerns. Why are we concerned about the overuse of these medications in borderline cases?
Sid Feldman: Because they are harmful. Although they may have benefits, they also have significant harms. There was a good large case-control matched study in BMJ published in early 2024 that looked at a large cohort—35,000 or so—and matched each with 15 controls. It confirmed some old harms that we already knew about, like increased risk of falls and fractures, increased risk of stroke, increased risk of pneumonia—particularly pneumonia—but it also introduced some newer ones like acute kidney injury, which was much more common in folks on antipsychotic medications.
As we age and become more frail, particularly with dementia, the risk-benefit ratio of many medications changes. So the benefits are probably less than we think, and the harms are probably more than we think. That’s why the risk-benefit ratio may not make sense to use these drugs for this purpose in residents in long-term care.
Kevin Pho: You obviously practice in a long-term care facility; you’re familiar with the data. Give us a sense of how much more frequently they’re being used today as opposed to years back. You don’t need specific numbers, but just in general, how much more frequently are they used?
Sid Feldman: The rate across Canada was down to about 19 or 20 percent back in 2019 or 2020, and now it’s back up to 24 percent. In the best performing homes in the U.S., for example, they’d be well down in the single digits, perhaps 5 percent, maybe even lower.
There are absolutely people who should be on them, as we said. I don’t think the rate should ever be zero. If there’s a long-term care home where the rate is zero, I wonder what else they’re using to keep folks calm. But I think we have a lot of opportunity to make a difference here. One of the things we’ve noticed is a big difference between the provinces in Canada, which always speaks to a quality improvement opportunity. If one province is doing really well and another isn’t, it makes you wonder whether the underperforming one could learn something from the high-performer.
Kevin Pho: When it comes to agitation that may be related to dementia, what other choices are available to prescribing physicians?
Sid Feldman: You want to think about pharmacological and nonpharmacological strategies. In terms of pharmacology, there is evidence, as I said, for antipsychotics. There’s also good evidence for citalopram, for example. Carbamazepine has evidence, nabilone, interestingly, has good RCTs showing some benefit as well, and others are using medications like gabapentin, prazosin—there’s a wide range of other alternatives that we might consider.
The key when it comes to pharmacotherapy is to remember that the agitation of dementia doesn’t last forever. So while we’re prescribing for some period of time, once the symptoms are under control, the critical thing is to think about gradual dose reduction. Once symptoms are under control, you want to taper down the medication to see how the person might do without it. Often what we find is there may not be a “Hallelujah!” response with them playing piano again, but at least they’re no worse off than they were on the medication, and often they’re more alert, can cooperate more with care, and can enjoy programs more.
That’s the first piece—other possible drugs. But even more important, there’s good evidence that an individualized, patient-centered approach of nonpharmacological strategies can be highly effective for the treatment of behavioral symptoms of dementia. That might include music. Probably the standardized mean difference for music is actually better than for an antipsychotic—but it has to be personalized music. You might like country, I might like jazz, and if we mix it up, we’re going to get worse. Physical exercise can make a huge difference, because we all need to move. Exposure to the outdoors—human beings do better in outdoor environments. Animal or pet therapy has good evidence, even robotic pets. Aromatherapy has evidence. So there’s a whole list of non-drug strategies that might be helpful.
The knowledge and education of the folks taking care of our residents with dementia makes a huge difference as well—training people to go slowly, to smile, to explain what they’re doing before they do it, to understand each individual’s nonpharm magic bullets. That can make a really big difference, along with optimizing the environment.
Kevin Pho: A couple of questions regarding what you said. About the alternative classes you mentioned, like citalopram, gabapentin—are they used more on a preventive basis, or are they used for more acute episodes, similar to how we use some as-needed antipsychotics?
Sid Feldman: If someone is in the midst of really aggressive physical behavior—hitting everybody—you may need to use a short-term antipsychotic, for sure. But then, to manage behavioral symptoms longer term, some of these other drugs may be appropriate. We don’t tend to use them in anticipation of behavioral symptoms, because the behavioral symptoms of dementia are so highly variable. Not everyone is going to develop something that requires the use of medication. In fact, the majority don’t.
Kevin Pho: In terms of the nonpharmacological strategies you mentioned, what are some reasons why they’re not being used more frequently? Is it an education issue, a staffing issue? Because a lot of these strategies sound labor-intensive, and here in the United States, many long-term care facilities are barely surviving when it comes to staffing. What are some of the underlying causes for why those strategies aren’t used more frequently?
Sid Feldman: You’re absolutely right that staffing issues in long-term care, particularly since the COVID-19 pandemic, have been extreme in Canada, the U.S., and probably worldwide. Not having enough staff available to implement strategies in a consistent way is a big issue. Also, having the ability to train staff so they can do things consistently is critically important. If the day shift does things well, and the evening shift does things well, but the night shift doesn’t, you’re not that much further ahead. So yes, it’s getting that consistency.
What we’ve found in long-term care homes that have been able to implement nonpharm strategies is that, in fact, they have more time. Residents aren’t falling, they don’t have pneumonia, they’re not requiring two people and a Hoyer lift to move them in and out of bed because they’re off the medications causing extrapyramidal symptoms and stiffness. Once you take the plunge and implement some of these, it can lead to more time available for other care needs.
Kevin Pho: Some of the physicians listening to this podcast might be medical directors at such long-term care facilities. What are some strategies you could suggest to implement nonpharmacological approaches?
Sid Feldman: This is very much a team effort—a team sport. Having a group of individuals within the home working with the medical director to implement a more formal evaluation process—targeting the people who may be amenable to deprescribing, and then using one of the evidence-based approaches like the DICE approach. Helen Kales and her group developed that approach: you Describe the behavior, Investigate the causes, Create a plan for how you’re going to manage that person with individualized, patient-centered care, and then Evaluate using validated tools to see if you’ve been effective. If you’ve made some headway, you go back and again you describe what you’re seeing, investigate, create, evaluate. You repeat that in an iterative, interdisciplinary way to make changes.
Another opportunity is when residents come in from acute care hospitals. Often they have a delirium that may have been treated (appropriately or inappropriately) with an antipsychotic. Once they’re transferred into the nursing home, that may be a real opportunity to take the antipsychotic away and see how they do. That’s one window of opportunity—right at admission.
Another is folks who are on low-dose or just PRN medication. Often that low-dose medication—like a tiny 0.25 or 0.5 milligram dose of risperidone—maybe they don’t need it. Those are candidates for deprescribing. We’ve found that personal support workers (you might have a different term in the U.S. for them—health care aides) are often really good at identifying which of the people they’re caring for might have that window for deprescribing. Those would be some of our targets and approaches.
Kevin Pho: We’re talking to Sid Feldman. He’s a family and long-term care physician. He co-wrote the KevinMD article, “Antipsychotic use has been rising in long-term care homes, but we can do something about it.” Sid, let’s end with some take-home messages you want to leave with the KevinMD audience.
Sid Feldman: Sure. Antipsychotics are incredibly useful medications for some of our residents in long-term care. There are many people, though, for whom we have an opportunity to deprescribe. The use of nonpharm strategies can be incredibly helpful and can often take the place of an antipsychotic medication. For those who are on an antipsychotic, after behavioral stability has been achieved, a gradual dose reduction process is well worth trying because you might be successful more often than you think. Finally, there are other medications with some evidence behind them that can also be useful in treating misconduct in dementia.
Kevin Pho: Sid, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Sid Feldman: My pleasure, Kevin. Thanks so much for your interest.
