Off-label use of antipsychotic drugs in nursing home patients not tracked in rural Manitoba

A gap in Manitoba's reporting system means the majority of nursing homes in the province cannot monitor how many residents are being given antipsychotic drugs without a diagnosis.

Nearly one quarter of residents in Winnipeg's 38 care homes are being given these powerful medications without a shown clinical need, a CBC investigation revealed.

But the scale of the problem in the province's other 87 homes is unknown because data is not being collected and the homes do not publicly report these numbers.

Melissa Marchischuk's 87-year-old mother has dementia and lives in a nursing home in Minnedosa. 

For the last five years her mother has been given the antipsychotic risperidone. She said her mother was not diagnosed with a mental condition the drug is meant to treat.

"I think they just try to sedate them," Marchischuk told CBC News.

"But risperidone is not the correct way to sedate them or make them calm."

Antipsychotics like risperidone are used to treat a variety of mental health conditions, but mainly for those that include psychotic symptoms, such as schizophrenia or bipolar disorder. 

Risperidone can be used in the short term to treat severe dementia of the Alzheimer's type, according to Health Canada.

Marchischuk said her mother no longer walks and is in a reclinable wheelchair. She needs to be fed and offered water, and she doesn't always make sense when she speaks.

But on occasions when she had to go to hospital and was taken off all her medications, Marchischuk said her mom's cognitive abilities improved.

"Once she gets better, she goes back on the risperidone and all is lost," Marchischuk said.

"When mom was on risperidone, she was worse. Like the fears, and whatever the mind goes through with dementia, I felt was made worse. 

The Winnipeg Regional Health Authority tracks which residents are being given the drugs without a diagnosis and reports them to the Canadian Institute for Health Information.

The institute releases these numbers annually, allowing Winnipeggers to see how each nursing home is performing and which one is prescribing the most antipsychotics off-label. 

Provinces such as Alberta, British Columbia and Ontario also report these numbers to the institute, allowing an entire analysis of the province's use of  antipsychotics in care homes to occur.

The lack of data in Manitoba personal care homes outside of Winnipeg is problematic, says Dr. Samir Sinha, director of geriatrics at Sinai Health and University Health Network in Toronto.

"They may be performing much better than Winnipeg. They might be performing much worse. But when you don't actually have any data, you can't actually monitor what you're not actually measuring," Sinha said.

Manitoba Liberal party health critic Jon Gerrard agrees.  

"People in rural [nursing] homes are not second-class citizens. They deserve to have the same sort of monitoring and standards that people in Winnipeg have," he said.

The health regions outside of Winnipeg were able to provide a global figure to show the total percentage of residents on anti-psychotics. The figures show rates were much higher outside of Winnipeg.

The number does not separate those who are diagnosed with a condition that could necessitate the medication versus those who are being given the drugs off-label to treat dementia or control behaviour.

They also do not provide a breakdown of the percentage for each nursing home.

Percentage of residents on antipsychotics in July/August 2022:

• Interlake-Eastern Regional Health Authority – 35.7%
• Northern Health Region – 33.2%
• Prairie Mountain Health – 31.6%
• Southern Health – 29.5%
• Winnipeg Regional Health Authority – 28.4%

Sinha says the public and health professionals need to know all the information surrounding the use of these drugs so they can ask the right questions.

"In these settings where they have higher rates of antipsychotic prescription, are there higher rates of diagnosed psychosis, for example, that would require these medications?" he said.

"Is that a justifiable variation or is there something that tells us there's an opportunity to improve the quality of care being provided?" he asked.

"[Or] another factor that may need to be understood further?"

Drug use monitored every 3 months: health regions

The four health regions outside of Winnipeg provided statements on how they monitor antipsychotic use within their homes.

All told CBC News, as per Manitoba Health policy, that individual medication reviews are completed every three months for every resident. 

Often the use of these medications begins before the resident is admitted to a home, so getting the resident off requires a "structured approach," said a spokesperson for Prairie Mountain Health.

During the three-month medication reviews, residents are reassesed and "opportunities for dose reduction or discontinuation" are explored, according to a spokesperson for the Interlake-Eastern Regional Health Authority.

When asked Wednesday if they would consider getting rural nursing homes to start tracking this, Health Minister Audrey Gordon said it was "up to clinicians."

"If the families feel there is a gap in the data that is being collected or the tracking of information we can certainly take that back to the leadership of the region and the leadership of Shared Health," she said.

Draper Houston, the minister's spokesperson, declined to answer if the government would commit to changing the reporting structure for rural health regions.

Instead he offered a brief statement stating that, "all regional health authorities review medications with patients on a regular basis." 

Marchischuk says it is time that the rest of Manitoba catches up with Winnipeg when it comes to reporting on the use of these drugs.

"It needs to be tracked," she said.