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ODPRN Report

April, 2014

Antipsychotic and Sedative Use in Long-Term Care (LTC) Homes in Ontario

KEY FINDINGS: Characteristics of Users in LTC Homes Aged 65 and Older (Table 1)  In fiscal year (FY) 2012, there were 93,489 ODB beneficiaries living in LTC homes in Ontario, 38.0% (N=35,506) of whom were dispensed an antipsychotic.  Among LTC residents, 2.7% (N=2,600) received only first generation , 31.5% (N=29,405) received only second generation antipsychotics and 3.7% (N=3,501) received both first and second generation antipsychotics (i.e. mixed group) over the year.  The prevalence of antipsychotic use decreased as age increased, from 46.2% (N=1,814 of 3,924) among patients aged 65-69 to 24.2% (N=277 of 1,144) among patients aged 100-104.  This trend in antipsychotic use by age was observed for first generation (4.1% aged 65-69 to 2.7% aged 100-104), second generation (35.0% aged 65-69 to 19.8% aged 100-104) and the mixed group (7.1% aged 65-69 to 2.8% aged 100-104) antipsychotics.  Concomitant antipsychotic and sedative use: O 27.1% (N=25,286) of LTC residents received antipsychotics with no concomitant sedatives, 10.9% (N=10,220) were treated concomitantly with antipsychotics and sedatives, and 6.2% (N=5,826) were chronically treated with both antipsychotics and sedatives.  Concomitant antipsychotic and cholinesterase inhibitor (ChEI) use: o 13.3% (12,470) of LTC residents were treated concomitantly with antipsychotics and ChEIs, the majority of which (91.4%; N=11,397) had chronic ChEI use.

Characteristics of Sedative Users in LTC Homes Aged 65 and Older (Table 2)  In 2012, 26.9% (N=25,184) of LTC residents had a prescription for a sedative.  The use of sedatives in LTC homes tended to decrease with age. Sedative use was highest among patients aged 65-69 (34.8%; N=1,353 of 3,890), falling to 25.7% (N=13,334 of 52,036) among patients aged 85 and older.

Concomitant Use of Sedatives and Antipsychotics in LTC Homes, by Age Group (Table 3)  Antipsychotic use with any concomitant sedative use: O In LTC homes, the number of patients taking an antipsychotic with a concomitant sedative decreased with increasing age: . 20.0% of LTC patients aged 65-69 (N=735 of 3,924) used both antipsychotics and sedatives. . 5.1% of LTC patients aged 100-104 (N=58 of 1,144) used both antipsychotics and sedatives. O This trend was observed for all types of antipsychotics.  Chronic use of both antipsychotics and sedatives: O In LTC homes, the number of patients chronically treated with both antipsychotics and sedatives also decreased with increasing age: . 13.5% of LTC patients aged 65-69 (N=531 of 3,924) were chronically treated with both agents. . 2.3% of LTC patients aged 100-104 (N=26 of 1,144) were chronically treated with both agents. O This trend was observed for all types of antipsychotics.

Contact: Tara Gomes Date: April 16, 2014 Email: [email protected] Page: 1 of 6 ODPRN Report

April, 2014

SCOPE OF THE ISSUE:  There is concern that antipsychotics and sedatives are being used inappropriately in LTC homes.  The Ontario Public Drug Program has requested information on use of antipsychotics, sedatives and cholinesterase inhibitors among ODB beneficiaries in LTC homes, to inform discussions regarding the inappropriate prescribing of these .

POLICY IMPLICATIONS:  While use of antipsychotics and sedatives appears high, their appropriateness could not be established with the data currently available.  More information is needed on the indication of use as well as on the specific products being prescribed to determine the appropriateness of antipsychotic and sedative use in LTC homes.

Contact: Tara Gomes Date: April 16, 2014 Email: [email protected] Page: 2 of 6 ODPRN Report

April, 2014

Table 1: Characteristics of antipsychotic users in LTC homes among ODB beneficiaries aged 65 and older First Second Mixed (1st Generation Generation and 2nd All Antipsychotics Antipsychotics Generation) LTC Antipsychotics Only Only Antipsychotics Denominator Antipsychotic Users 35,506 (38.0%) 2,600 (2.8%) 29,405 (31.5%) 3,501 (3.7%) 93,489 Antipsychotic Use by Age Group 65-69 1,814 (46.2%) 162 (4.1%) 1,375 (35.0%) 277 (7.1%) 3,924 70-74 2,835 (45.9%) 223 (3.6%) 2,260 (36.6%) 352 (5.7%) 6,181 75-79 5,017 (43.9%) 302 (2.6%) 4,117 (36.0%) 598 (5.2%) 11,439 80-84 8,101 (40.6%) 532 (2.7%) 6,745 (33.8%) 824 (4.1%) 19,948 85-89 9,247 (36.3%) 632 (2.5%) 7,846 (30.8%) 769 (3.0%) 25,503 90-94 6,178 (33.3%) 493 (2.7%) 5,183 (28.0%) 502 (2.7%) 18,534 95-99 2,037 (29.9%) 225 (3.3%) 1,653 (24.3%) 159 (2.3%) 6,816 100-104 277 (24.2%) 31 (2.7%) 226 (19.8%) 20 (1.8%) 1,144 Concomitant Antipsychotic and Sedative

Use Antipsychotics, No sedatives 25,286 (27.1%) 1,997 (2.1%) 21,277 (22.8%) 2,012 (2.2%) 93,489 Antipsychotic and Sedative User1 10,220 (10.9%) 603 (0.6%) 8,128 (8.7%) 1,489 (1.6%) 93,489 Chronic Antipsychotic and Sedative User2 5,826 (6.2%) 231 (0.3%) 4,812 (5.2%) 783 (0.8%) 93,489 Concomitant Antipsychotic and

Cholinesterase Inhibitor (ChEI) Use Antipsychotics, No ChEI 23,036 (24.6%) 2,342 (2.5%) 18,382 (19.7%) 2,312 (2.5%) 93,489 Antipsychotic and ChEI User1 12,470 (13.3%) 258 (0.3%) 11,023 (11.8%) 1,189 (1.3%) 93,489 Chronic Antipsychotic and ChEI User2 11,397 (12.2%) 147 (0.2%) 10,166 (10.9%) 1,084 (1.2%) 93,489 1User defined as 1 or more prescriptions during continuous antipsychotic treatment. 2Chronic user defined as 4 or more prescriptions during continuous antipsychotic treatment

Contact: Tara Gomes Date: April 16, 2014 Email: [email protected] Page: 3 of 6 ODPRN Report

April, 2014

Table 2: Characteristics of sedative users in LTC homes among ODB beneficiaries aged 65 and older LTC Sedative Users Denominator Sedative User (N, %) 25,184 (26.9%) 93,489 Sedative Use by Age Group (N, %) 65-69 1,353 (34.8%) 3,890 70-74 1,988 (32.0%) 6,220 75-79 3,228 (28.3%) 11,391 80-84 5,261 (26.4%) 19,952 85-89 6,457 (25.4%) 25,457 90-94 4,806 (25.8%) 18,599 95-99 1,767 (25.9%) 6,833 100-104 306 (26.7%) 1,147

Contact: Tara Gomes Date: April 16, 2014 Email: [email protected] Page: 4 of 6 ODPRN Report

April, 2014

Table 3: Concomitant use of sedatives and antipsychotics in LTC homes among ODB beneficiaries aged 65 and older, by age group First Second Mixed (1st Generation Generation and 2nd All Antipsychotics Antipsychotics Generation) LTC Antipsychotics Only Only Antipsychotics Denominator Antipsychotic Use with No Concomitant Sedative use (N, %) 65-69 1,079 (27.5%) 113 (2.9%) 846 (21.6%) 120 (3.1%) 3,924 70-74 1,816 (29.4%) 148 (2.4%) 1,486 (24.0%) 182 (2.9%) 6,181 75-79 3,436 (30.0%) 226 (2.0%) 2,872 (25.1%) 338 (3.0%) 11,439 80-84 5,872 (29.4%) 403 (2.0%) 4,981 (25.0%) 488 (2.5%) 19,948 85-89 6,737 (26.4%) 499 (2.0%) 5,776 (22.6%) 462 (1.8%) 25,503 90-94 4,559 (24.6%) 399 (2.2%) 3,852 (20.8%) 308 (1.7%) 18,534 95-99 1,568 (23.0%) 180 (2.6%) 1,289 (18.9%) 99 (1.5%) 6,816 100-104 219 (19.1%) 29 (2.5%) 175 (15.3%) 15 (1.3%) 1,144 Antipsychotic Use with Concomitant Sedative use1 (N, %) 65-69 735 (20.0%) 49 (1.3%) 529 (13.5%) 157 (4.0%) 3,924 70-74 1,019 (16.5%) 75 (1.2%) 774 (12.5%) 170 (2.8%) 6,181 75-79 1,581 (13.8%) 76 (0.7%) 1,245 (10.9%) 260 (2.3%) 11,439 80-84 2,229 (11.2%) 129 (0.7%) 1,764 (8.8%) 336 (1.7%) 19,948 85-89 2,510 (9.8%) 133 (0.5%) 2,070 (8.1%) 307 (1.2%) 25,503 90-94 1,619 (8.7%) 94 (0.5%) 1,331 (7.2%) 194 (1.1%) 18,534 95-99 469 (6.9%) * * * 6,816 100-104 58 (5.1%) ≤5 * ≤5 1,144 Chronic Antipsychotic Use with Concomitant Sedative Use2 (N, %) 65-69 531 (13.5%) 32 (0.8%) 380 (9.7%) 119 (3.0%) 3,924 70-74 675 (10.9%) 40 (0.7%) 531 (8.6%) 104 (1.7%) 6,181 75-79 930 (8.1%) 35 (0.3%) 744 (6.5%) 151 (1.3%) 11,439 80-84 1,258 (6.3%) 50 (0.3%) 1,034 (5.2%) 174 (0.9%) 19,948 85-89 1,319 (5.2%) 41 (0.2%) 1,148 (4.5%) 130 (0.5%) 25,503 90-94 863 (4.7%) 25 (0.1%) 760 (4.1%) 78 (0.4%) 18,534 95-99 224 (3.3%) 8 (0.1%) 189 (2.8%) 27 (0.4%) 6,816 100-104 26 (2.3%) 0 (0.0%) 26 (2.3%) 0 (0.0%) 1,144 1Concomitant user defined as 1 or more prescriptions during continuous antipsychotic treatment. 2Chronic Concomitant user defined as 4 or more prescriptions during continuous antipsychotic treatment. Note: information suppressed for Antipsychotic Use with Concomitant Sedative use due to small cell sizes.

Contact: Tara Gomes Date: April 16, 2014 Email: [email protected] Page: 5 of 6 ODPRN Report

April, 2014

OVERVIEW OF METHODOLOGY:

1. Design  Study Design: Cohort Study  Study Period: April 1, 2012-March 31, 2013  Patient Population: Patients who live in LTC homes in Ontario, between April 1, 2012 and March 31, 2013  Eligibility Criteria o Alive on April 1, 2012 o Aged 65+ on April 1, 2012 o Aged 104 or younger on April 1, 2012  Follow-up: Period of continuous use of antipsychotics was defined over the study period (no more than 90 days could elapse between prescriptions).  The LTC Continuing Care Reporting System (CCRS) was used to identify people residing in LTC homes and the Ontario Drug Benefit (ODB) database was used to identify antipsychotic, sedative and cholinesterase inhibitors users.  Study drugs defined as: o First generation antipsychotics: , , , , , , , methotrimeprazine, , , , , , thiopropazate, , , thiothixazine, , . o Second generation antipsychotics: , , , , , , . o Sedatives: alprazolam, bromazepam, chlordiazepoxide, clonazepam, clorazepate, diazepam, flurazepam, lorazepam, methotrimeprazine, nitrazepam, oxazepam, temazepam, triazolam. o Cholinesterase Inhibitors: donepezil, , rivastigmine.  Patients were stratified based on: o Type of antipsychotics dispensed over the period of continuous use (first generation only, second generation only, both first and second generation (mixed)) o Concomitant use of sedatives: . No concomitant sedative use . Any concomitant sedative use: defined as at least 1 prescription for a sedative over the period of continuous antipsychotic use . Chronic sedative use: defined as at least 4 prescriptions for a sedative over the period of continuous antipsychotic use o Concomitant use of cholinesterase inhibitors (ChEIs): . No concomitant ChEI use . Any concomitant ChEI use: defined as at least 1 prescription for a ChEI over the period of continuous antipsychotic use . Chronic ChEI use: defined as at least 4 prescriptions for a ChEI over the period of continuous antipsychotic use o Age group (65-69, 70-74, 75-79, 80-84, 85-89, 90-94, 95-99, 100-104)  Characteristics of sedative users were defined based on individuals receiving at least one sedative prescription over the study period. o Analyses were stratified by age group (same groups as above)  Over follow-up, we identified: o Number of LTC residents o Age of LTC residents, defined as age at first prescription or April 1, 2012 if no prescription o Number of LTC residents treated with antipsychotics o Number of LTC residents treated with sedatives o Number of LTC residents treated with both antipsychotics and sedatives o Number of LTC residents treated with both antipsychotics and cholinesterase inhibitors

Contact: Tara Gomes Date: April 16, 2014 Email: [email protected] Page: 6 of 6