Antipsychotic medications don’t always work the way they’re supposed to

A new study conducted by researchers at the University of Waterloo analyzed data from nearly 500,000 Canadian patients who lived in nursing homes across Canada between 2000 and 2022. It found that residents who were given antipsychotic medications showed a significant worsening of their behaviours. In fact, nearly 68 per cent of residents who used antipsychotics had more problems with their behaviour during follow-up checks.

“This is the first national longitudinal study of its kind, using a statistical technique to measure the effect of antipsychotic treatments,” said Dr. Daniel Leme, the study’s lead author and a postdoctoral scholar in Waterloo’s School of Public Health Sciences.

Antipsychotics are often prescribed in nursing homes “off-label,” meaning they’re used for purposes not approved by health authorities like the U.S. Food and Drug Administration (FDA). For example, they might be given to manage behaviours associated with dementia, even though these drugs are only approved for treating conditions like schizophrenia or certain types of psychosis. The study found that 26 per cent of nursing home residents in Canada were given antipsychotics in ways not recommended by the FDA between 2014 and 2020.

Although antipsychotics are often used to calm residents with aggressive or agitated behaviour, the medications can have serious side effects. These include tremors, restlessness, rigidity, painful muscle contractions and the inability to stand and walk, which can exacerbate existing behavioural and psychological symptoms.

“Sometimes people may say they don’t have enough staff to deal with these issues, but the reality is that these medications can make disability and cognitive impairment worse,” said Dr. John Hirdes, a professor in the School of Public Health Sciences. “We need to seriously reconsider the use of antipsychotics for people who do not have conditions associated with psychosis.”

The study outlines the inappropriate use of antipsychotics to treat behavioural and psychological symptoms of dementia (BPSD), which can include irritability, aggression, agitation, anxiety, depression, sleep or appetite changes, apathy, wandering, repetitive questioning, sexually inappropriate behaviours and refusal of care.

Instead of turning to medication right away, researchers suggest focusing on person-centred care — getting to the root causes of a resident’s behaviour and offering support in other ways. For example, a resident might need better pain management, clearer communication, or activities to help reduce anxiety. Non-drug therapies like music, art, social interaction, and gentle exercise have been shown to help manage behaviour without the need for antipsychotics.

Training staff to understand the risks of antipsychotics and how to offer better care has also been linked to improved outcomes for nursing home residents, including less agitation and a better quality of life.

The study, published in the November 2024 issue of the Journal of the American Medical Directors Association, is part of an international project called I-Care4Old, and was funded by the New Frontiers Research Fund Global Grant.