**The Surge of Antipsychotic Utilization in Long-Term Care Homes: Obstacles and Solutions**

In recent times, there has been a troubling rise in the application of antipsychotic medications within long-term care homes—an issue brought to light by Sid Feldman, a physician specializing in family and long-term care, during his conversation on the KevinMD podcast. Feldman notes that although antipsychotics can be extremely helpful for specific conditions, their excessive application for managing behavioral symptoms of dementia prompts serious ethical, clinical, and safety issues. This article delves into the escalating dependence on these medications and examines alternative methods to tackle the challenges in caring for elderly individuals.

### The Present State of Antipsychotic Utilization

Antipsychotics, especially atypical variants like risperidone, olanzapine, and quetiapine, are commonly prescribed to control psychosis, severe mental disorders, and behavioral symptoms related to dementia. Nevertheless, recent data from Canada’s long-term care institutions reveals a notable rise in prescription rates, which had previously been on the decline before the COVID-19 pandemic—increasing from 19-20% in 2019 to around 24% in more recent times. In contrast, some high-performing facilities in the United States report usage rates as low as 5%.

Feldman attributes part of this increase to the pandemic, during which long-term care homes were confronted with unprecedented staffing shortages, heavy patient loads, and a total disruption of usual routines. In these circumstances, antipsychotics might have offered a quick solution to manage agitation and aggression among dementia residents. However, this growing dependence on such drugs has sparked renewed discussions about their potential dangers and necessity.

### The Dangers of Over-Prescribing

Feldman highlights that while antipsychotics can be beneficial when prescribed appropriately, they may also present considerable risks:

1. **Increased Health Complications**: Studies have consistently connected antipsychotic usage to serious side effects, including falls, fractures, strokes, and respiratory illnesses such as pneumonia. Newly emerging data, including a 2024 BMJ study, also links these medications to acute kidney injuries.

2. **Diminished Quality of Life**: Although these medications can alleviate aggression or agitation, they might also sedate residents to the extent that their alertness diminishes and their engagement in daily activities is limited. This contradicts the goal of fostering meaningful, person-centered care in long-term facilities.

3. **Ethical Issues**: The reliance on antipsychotics as a standard behavioral management strategy—particularly in borderline or mild cases of aggression—raises ethical concerns regarding overmedicalization. Furthermore, there are worries that treatment may be prioritized over seeking therapeutic alternatives.

### Alternatives to Antipsychotics: A Comprehensive Approach

Healthcare professionals and caregivers have access to a variety of pharmacological and nonpharmacological tactics. A vital point from Feldman’s discussion centers around shifting the emphasis toward treatments that prioritize individual well-being, reduce drug-related risks, and utilize team-based care frameworks.

#### 1. **Nonpharmacological Approaches**
Nonpharmacological interventions frequently yield comparable or even superior benefits compared to medications, enhancing residents’ overall quality of life. However, these strategies necessitate coordinated efforts, sufficient staffing, and continuous education:

– **Personalized Activities**: Customized music therapy (e.g., jazz for one resident, classical for another) can calm agitation. Physical activity, exposure to outdoor settings, and sensory interventions such as aromatherapy or pet therapy have also proven effective.
– **Caregiver Training**: Training staff in methods like speaking softly, clarifying care procedures, and catering to an individual’s habits can alleviate distressing behaviors without the need for medication.
– **Environmental Modifications**: Minimizing noise, ensuring appropriate lighting, and establishing familiar routines can help create a tranquil setting.

#### 2. **Alternative Medications**
While antipsychotics may be essential in severe instances of aggression or psychosis, other medication options should be explored, including:
– **Citalopram and Carbamazepine**: These medications have shown effectiveness in managing mood disorders or behavioral problems.
– **Nabilone**: Emerging studies indicate that cannabis-derived medications may offer advantages in behavioral management and pain relief.
– **Short-Term Antipsychotic Use**: In critical situations, antipsychotics may be prescribed temporarily and reduced progressively once symptoms stabilize.

#### 3. **The Important Role of Deprescribing**
Gradual dose tapering is an evidence-based method enabling physicians to assess whether a resident’s symptoms can be controlled without medication. Often, residents either remain stable or even exhibit improvements in alertness, participation, and cooperation when antipsychotics are discontinued under close monitoring.

### Challenges to Adopting Nonpharmacological Care

Despite the increasing recognition of the effectiveness of nonpharmacological methods, their implementation within long-term care facilities remains uneven. Factors contributing to this dilemma include:
– **Staff Shortages**: Insufficient staffing