This article was published 13/6/2015 (2128 days ago), so information in it may no longer be current.
Trish Rawsthorne recalls her revulsion, four decades ago, when she visited city personal care homes as a nursing student and witnessed the way many elderly were controlled.
The residents were often placed in restraint chairs, bound by bed sheets.
"They would wrap them around the chair arms, around the person and tie them around the back so they couldn’t undo them," Rawsthorne said. "My reaction to that was one of disgust, that this is not caring for people. This is warehousing people in an institutional setting."
Her intention, upon graduation from the then Red River Community College diploma nursing program, was to help "rehabilitate and reform" nursing homes. But when a job wasn’t available in the area, her career took a different path. She found work at a respiratory centre at Health Sciences Centre and later held a series of health administration jobs before retiring in 2012.
Now 65 years old, with both her mother and her sister residing in a city personal care home, Rawsthorne is dismayed that, in some respects, things haven’t changed in the past four decades. But instead of being tied down with bed sheets, residents are being restrained by chemicals.
According to data from the Winnipeg Regional Health Authority, more than 1,000 Winnipeg nursing home residents at any one time are being placed on powerful antipsychotic drugs to control their behaviour — even though they’ve not been diagnosed with illnesses such as schizophrenia.
The drugs are being administered to manage a sometimes unpredictable population in a system many say is chronically understaffed.
The medications are being administered despite numerous studies linking them to increased risk of falls and fractures, stroke and sudden cardiac death.
The drugs render the elderly residents less mobile and less apt to wander, and can prevent dementia sufferers from lashing out.
In a few city care homes — Oakview Place and Riverview Health Centre — as many as one in three residents are being prescribed these medications.
This ‘off-label’ use of anti-psychotic drugs is not unique to Winnipeg. It’s an issue confronting health authorities across the country.
In Ontario, about one-third of nursing home residents, on average, are prescribed anti-psychotic drugs, with some institutions exceeding 50 per cent use, the Toronto Star reported last year.
In a report two years ago, the Canadian Institute for Health Information pegged off-label antipsychotic drug use in Winnipeg nursing homes at 24 per cent — or on the lower end of reporting regions across the country. More recent data provided by the WRHA puts the use at just over 20 per cent.
Experts say some off-label use of antipsychotics such as risperidone and olanzapine, which are used to treat schizophrenia, may be warranted, but the level of use in many Canadian nursing homes is too high.
According to the Canadian Geriatrics Society, the drugs provide limited benefit to dementia patients and can cause serious harm, including premature death. It says their use should be limited to cases where other methods have failed and patients pose an imminent threat to themselves or others.
A local pharmacological expert said it is "totally unjustified" for a personal care home to have as many as 30 per cent of its residents on antipsychotic drugs without a diagnosis of psychosis.
"The bottom line is that there have not been sufficient appropriate clinical trials to solidify the risk-benefit ratio for these compounds," said Daniel Sitar, professor emeritus with the University of Manitoba’s department of pharmacology and therapeutics.
Sitar, acting director of the U of M’s Centre on Aging, said some patients with dementia may be lashing out simply because they are in pain and lack the ability to communicate their suffering to caregivers.
"If you’re going to do something to me and I know it’s going to hurt, I’m going to respond in any way I know how to respond," he said.
Sitar advocates administering a non-opiate pain-reliever such as acetaminophen (Tylenol) for a time to see if a resident’s behaviour changes before resorting to more drastic treatments.
But that takes time and nursing homes are often short-staffed.
"I don’t think there is malice with the use of chemical restraints, but it’s sure as hell convenient," Sitar said.
In his opinion, too many people are placed on antipsychotics without "a vigorous justification," The monitoring of dosages — and their escalation — is "probably inadequate," he said.
Personal Care Homes in Winnipeg, and their use of antipsychotic medication for patients without diagnosis of psychosis
This map shows personal care homes in Winnipeg. Click on a pointer to see the average percentage of residents who received antipsychotic medication without having a diagnosis of psychosis, from April 1, 2013 to Sept. 30, 2014
= 5.6 to 15 per cent = 15 to 20 per cent = 20 to 25 per cent = 25 to 34.3 per cent
Mavis Turner, Trish Rawsthorne’s 94-year-old mother, worked as a student counsellor for many years at University of Winnipeg. A home economics graduate, she loved to travel and socialize and had a wide circle of friends.
But a few years ago, Turner could no longer live independently. She was placed in supportive housing, where seniors who do not suffer serious health problems and are generally mobile receive basic services such as having their meals prepared and reminders on when to take medications.
The facilities are secured to ensure clients don’t wander off, and the locked doors didn’t sit well with Turner. "She didn’t like being confined," Rawsthorne said.
So she was placed on antidepressants and the antipsychotic risperidone.
Rawsthorne believes the medications led to urinary incontinence, which necessitated moving Turner last summer to Misericordia Place, a personal care home, where she continues to receive the powerful drugs.
She said her mom has been on a downward spiral ever since. The elderly woman is no longer able to go to the bathroom on her own and needs assistance getting from her bed to her chair. She is receiving less stimulation than before.
"If you saw the pictures of her (last) June before she came here you’ll see the difference," Rawsthorne told the Free Press during a visit this winter to the nursing home. "Her decline has been spectacular. I’ve never seen somebody decline so rapidly."
A few months ago, Turner was able to amble on her own with the aid of a walker. However, her daughter said she now needs help to walk. Rawsthorne said her mother’s leg muscles have deteriorated, and a new antipsychotic drug she has been placed on has affected her balance.
Turner has already had a couple of mishaps. A few months ago, while in a wheelchair, she flipped over backwards and banged her head, requiring stitches. Another time, she sustained a nasty bruise on her head after falling against her night table. More recently, she has sustained unexplained bruising to her right arm.
Critical incidents in personal care homesClick to Expand
A personal care home resident has difficulty breathing and swallowing. It takes staff 24 hours to discover that a bottom denture has lodged at the back of the person’s throat.
A nursing home resident known to be at a high risk of choking is found unresponsive in a wheelchair in a dining room. Apparently, the resident had snatched a doughnut from a box left on the dining room table, choked on it and died.
A PCH resident is to receive a blood thinner upon returning from hospital, but it isn’t administered for four days. On the fourth day, the person suffers a stroke.
These are three of 56 critical incidents involving personal care home residents that occurred in the first three months of last year — the most recent quarterly report available from Manitoba Health.
During that period, cases involving personal care homes accounted for 63 per cent of the 89 critical incidents in the Manitoba health system.
Most PCH critical incidents — literally dozens — involved broken hips or other bones due to falls. Several other incidents were due to severe pressure ulcers or bed sores.
Each quarterly report contains only brief, cryptic descriptions of the incidents. They do not list the sex of the individual, the location of the incident or even the health region where it occurred. So there is no way of knowing if a particular care home has more than its share of incidents.
During the first quarter of last year, three incidents resulted from apparent confrontations between residents.
In one case, a nurse heard two people having a "verbal confrontation." One resident was found lying on a hallway floor with a fractured hip.
In another case, an "ambulatory PCH resident was kicked by (a) co-resident sitting in a wheelchair." The victim fell backwards and fractured their hip.
In a third case, a resident was seen pushing another. The victim fell and fractured their hip.
Sometimes, severe injuries in personal care homes are not immediately detected. In one case in early 2014, a resident complained of severe leg and groin pain. The person had fallen four weeks earlier. It was discovered the resident had a fractured hip and needed surgery.
In 2013, there were 456 critical incidents involving major injury or death reported to Manitoba Health, of which 244 (54 per cent) involved the province’s personal care homes. The remainder occurred in hospitals or from clients receiving home care.
The description of one 2013 personal care home incident, causing death, is a real head-scratcher.
It read: "PCH resident had unwitnessed fall resulting in fractured hip. Surgical repair slated. The following day, resident died. Unclear if surgery proceeded."
Of 56 critical incidents involving Manitoba personal care home patients in the first three months of 2014:
- 41 involved broken bones due to falls;
- 11 were due to severe pressure ulcers or bed sores;
- one involved the failure to administer an anti-coagulant medication;
- one involved a resident susceptible to choking who picked up a doughnut from a dining room table, choked on it and died;
- one required surgery to relieve pressure on their brain after suffering a fall in which they hit their head; and
- one developed difficulty breathing and swallowing. It wasn’t until 24 hours later that a bottom denture was found lodged at the back of the resident’s throat. The resident developed pneumonia and died three weeks later.
Source: Critical Incidents Reported to Manitoba Health, Jan. 1, 2014 to March 31, 2014.
When a reporter visited at around 11 a.m. one morning, Turner was asleep. Rawsthorne awakened her and asked her if she would like some water. There was a cup and straw on the night table. She hadn’t had breakfast.
Rawsthorne fetched some cold water from a pitcher in the refrigerator down the hall.
Turner needed help to drink. "Oh, that was good!" she exclaimed after taking a sip.
A health care aide came in to change her. From down the hall, where Rawsthorne and I had retreated, her mother gives out a series of distressed cries.
"Whatever they’re doing, she’s objecting," Rawsthorne remarked. But her mother continued to utter the cries — which got louder whenever she appeared impatient or frustrated — long after the aide departed.
Rawsthorne later said she believes her mother’s frequent and disquieting vocalizations are related to the use of antipsychotic drugs. A potential side effect of these drugs is akathisia, a movement disorder characterized by a feeling of inner restlessness.
"I first heard her do this when she was moved to Misericordia Place — I would say at least two months after," Rawsthorne said. "They decided after a few months to stop the use of risperidone and they gave her a break for a while, then about a month ago they started her again on another anti-psychotic Abilify – same as the others, just newer.
"She displays less episodes of the crying out but I suspect when she does it is in relation to the incontinence of urine and stool that she is experiencing on these drugs and the fact that the staff do not practice any type of toileting routines for residents.
"They were giving her Ativan (used to treat anxiety disorders) as well, which for awhile there made her so stuporous that she could not talk hardly at all and fell asleep all the time."
Rawsthorne does not have power of attorney for her mom — another family member does — so she is unable to challenge the use of the drugs provided to her mother.
'Prescribing is easy; diagnosing is hard'
The Winnipeg Regional Health Authority says it wants to greatly reduce the amount of off-label use for antipsychotic drugs in personal care homes.
At one time, about 30 per cent of residents were prescribed these drugs, which can increase the incidence of falls and even death.
More recently, the number dropped to 21 per cent. And now, the region is aiming to lower it further — to between five and 15 per cent.
"We know that we have some work to do," said Allison Bell, pharmacy manager with the WRHA’s personal care home program.
The WRHA has initiated a number of strategies to reduce its use of chemical restraints, Bell said.
It has rolled out a program, originating in Ontario, that promotes creative solutions to dealing with nursing home residents with dementia.
Known best by its acronym PIECES, the program encourages institutions to develop teams to assess residents’ physical, emotional and intellectual capabilities to better manage challenging behaviours such as aggression, wandering and anxiety. Under the program, the use of antipsychotic drugs is viewed as a last resort — rather than an automatic response in dealing with negative behaviour.
However, implementing the program takes time and effort. It involves learning about a resident’s personal history, what they did for a career, how they liked to spend their free time. The strategies vary. What works for one resident may not work for another.
So far, the program has been implemented with varying degrees of success throughout the city’s more than three dozen personal care homes.
"Prescribing is easy; diagnosing is hard," said Preetha Krishnan, a nurse practitioner who has been instrumental in reducing the use of antipsychotic drugs at Lions Personal Care Centre to less than five per cent.
Another way to reduce the reliance on drugs is to change the culture of care to one that is more patient-centred, rather than staff-centred, she said.
In staff-centred institutions, meals are served at preordained times, not when residents are hungry. People are bathed on certain days of the week, not when they want to be bathed. Residents are put to bed when they’re not sleepy. The resulting distress is treated with medications.
The WRHA recently undertook a project in which questionable prescribing behaviours in some nursing homes were flagged with the assistance of a computerized monitoring program. The project tracked high-frequency prescriptions of antipsychotics by certain doctors as well as instances where the medications were used long-term.
"We gave the prescribers data about their practice. We showed the amount of antipsychotics and what type of antipsychotics they were prescribing," said Bell. "And we equipped them with evidence-informed practice documents to show, ‘Here’s the evidence to show when antipsychotics should be used and when they shouldn’t be used and how to discontinue them.’"
The region plans to expand the program in the future, Bell said.
Sympathy without commitment
The Manitoba government funds personal care homes at a level that theoretically allows them to provide 3.6 hours of patient care per day. It says this level of staffing is among the highest in the country.
However, it is debatable whether nursing homes can implement some of the recommended strategies for reducing their reliance on chemical restraints under current staffing conditions. It’s long been suggested there is a link. And those who work in the field say they are already stretched to the max.
Firstly, the 3.6-hour standard translates to more like 3.1 or 3.2 hours per day once sick time and vacation time is factored in.
The Canadian Union of Public Employees, which represents 3,000 Manitoba health care aides, dietary aides, and other nursing home employees, recently told Health Minister Sharon Blady that current staff funding levels fail to meet "basic safety requirements."
The union said residents’ basic care needs are being met, but only because staff are completing tasks on their own time at the risk of burnout.
CUPE national staff rep Laurissa Smerchanski-Sims said the union advised the minister that in order to meet basic requirements, staffing levels — actual productive hours, not funded hours — need to climb to 4.1 hours per resident per day.
"To meet the basic and intensive needs of residents we recommend a level between 4.5 and 4.8 hours of actual care," Smerchanski-Sims said in an interview.
"They were giving her Ativan as well, which for awhile there made her so stuporous that she could not talk hardly at all and fell asleep all the time." ‐ Trish Rawsthorne
She said Blady was sympathetic but made no commitments to increased staff funding. It’s doubtful the government would boost such funding at a time when it’s under pressure to eliminate its budgetary deficit.
Health care aides generally provide about 70 per cent of the hands-on care in Manitoba personal care homes with registered nurses and licensed practical nurses providing the rest.
Sheila Novek, a Winnipeg PhD student who has done research into the backgrounds and training of health care aides among other issues, said staffing levels in Manitoba nursing homes have failed to keep up with the increasing complexity of resident care needs.
"We know that residents are sicker and require higher levels of care (than ever before)," she said.
That’s because improvements in home care and new supportive housing facilities have effectively delayed — if not eliminated — entry for many seniors into nursing homes.
Novek, who once created a change.org website devoted to raising awareness about the inadequacy of personal care home staffing, decried the lack of Canadian research into personal care home staffing needs. U.S. studies peg staffing requirements somewhere above four hours per resident, depending on the needs of the nursing home population.
Novek termed the 3.6-hour standard established by Manitoba "arbitrary" and "not evidence based." She said the province needs to fund a study to determine safe and adequate staffing levels.
If staffing is already inadequate, how can the system implement good ideas for improving care? Novek asked.
And it’s not like nursing home residents, the vast majority of whom are suffering from dementia, can speak up for themselves, she said. "They don’t have a political voice to say, ‘We need more staff. The quality of care is not adequate.’ And that may be why we’re not seeing change on an issue that everyone in the industry knows is a problem."
Novek is completing a doctorate at the U of M in community health sciences, with a focus on the early onset of dementia. She interviewed numerous health care aides at nursing homes while completing her master’s degree several years ago. She said they painted a troubling picture of a challenging work environment "where they were often forced to ration out care" and faced "moral dilemmas" as part of the job.
One dilemma was having to choose between two residents calling out for help simultaneously and only being able to respond to one. It might mean that one resident who needed to go to the washroom wound up wetting themselves and suffer the indignity of it, she said.
Gina Trinidad, the WRHA’s chief operating officer for long-term care, said nursing home care includes helping residents with the activities of daily living, including assistance with daily hygiene, grooming, dressing, feeding, oral care and medication management.
Personal care homes must complete monthly reports that include whether they are in compliance with provincially set staffing levels. By and large, the institutions are meeting their obligations, Trinidad said.
She agreed with the assessment funding and staffing levels were set at a time when residents’ medical and behavioural issues were less severe than they are today.
"That population has changed even from five years ago," Trinidad said.
Asked point blank if staffing levels are sufficient, she said: "It’s what we have."
Lorraine Dacombe Dewar, executive director of the continuing care branch of Manitoba Health, said the department is monitoring the increasing demands on personal care home staff.
The province is also participating in research with the Alberta faculty of nursing on methods of improving elder care in nursing homes, though its interest seems to suggest that it is more focused on increasing efficiencies in personal care homes than boosting staffing levels.
"We’re learning that it’s more than the basic numbers of staff that are actually contributing to high quality care through this work," said Dacombe Dewar. "So while the numbers are very important, and I think we will continue to be monitoring and assessing whether that guideline (funding of 3.6 hours of resident care per day) is appropriate as we go forward, I think we also need to look at some of the other things that make a contribution to quality of care."
An Ontario geriatric psychiatrist and researcher says the Winnipeg Regional Health Authority may be too ambitious in its attempt to reduce off-label use of antipsychotic drugs in nursing homes to between five and 15 per cent of residents.
In fact, said Dr. Dallas Seitz, the WRHA’s current target, if reached, could put some residents at risk.
Seitz said 10 to 20 per cent of nursing home residents with advanced dementia can be quite aggressive.
According to best-practices guidelines, the use of antipsychotic drugs may be considered as an option — for those not suffering from schizophrenia — if non-pharmacological treatments have failed and a patient’s behaviour is persistent, distressing or dangerous, he said.
Nurse practitioners make a differenceClick to Expand
Nurse practitioner Preetha Krishnan with Monica Allison, 97, at Lions Manor Personal Care Home. Joe Bryksa /Winnipeg Free Press
There are few studies that measure the impact of increased staffing levels in nursing homes.
But the Winnipeg Regional Health Authority is convinced the constant presence of a nurse practitioner in a long-term care facility can have huge cost and patient care benefits.
Nurse practitioner Preetha Krishnan has been working at Lions Manor Personal Care Home on Sherbrook Street since 2007.
During that time, hospital admissions for residents at Lions has fallen by 81 per cent and the number of emergency room visits was cut by 88 per cent. Annual drug costs at the home fell by $105,792 while the cost of hospital stays dropped by $167,000.
Meanwhile, the percentage of residents on antipsychotic drugs at Lions has also plunged.
When Krishnan began, 37.5 per cent of residents were on some form of antipsychotic drug. Now, only four per cent are.
Before she was hired, a physician typically visited the 130-resident facility once a week. But having a nurse practitioner nearly full-time — Krishnan’s caseload also includes 20 residents at Misericordia Place on Furby Street — had made a world of difference.
Krishnan is able to diagnose certain medical conditions, such as pneumonia, before they become more serious and require a trip to hospital. She acts as a resource for the other staff.
Gina Trinidad, the WRHA’s chief operating officer for long-term care, said if she could hire a couple of dozen more nurse practitioners to work in the city’s nursing homes she would.
"The model is very successful," she said.
"The nurse practitioners are on site. They’re working with the team. They’re part of the team. And they certainly build a lot of skill capacity with other nurses within the team."
Krishnan said many residents are already on antipsychotic drugs when they are admitted to a personal care home. She recalls one woman who was prescribed the powerful medications for a decade before arriving at Lions.
She talks to family members and social workers about why a person was put on the drug and when the resident is stable, she reduces the dosage. The results can be dramatic.
"They start walking. They’re dancing. They’re eating by themselves. They’ve got life," Krishnan said.
Nurse practitioners are registered nurses with advanced training (generally a masters degree in nursing) and experience, and they’re in great demand in clinics and hospitals.
The U of M college of nursing expects a dozen graduates from its nurse practitioner program this year. Last year, it increased admissions to the two-year, full-time program to 20.
As of the end of December, there were 149 NPs in Manitoba. Only three are currently employed by the WRHA in personal care homes.
"Our ability to recruit people who are specifically interested and have skills in long-term care is challenging," said Trinidad, noting it took eight months to recruit the last one — from Saskatchewan.
"If you can reach 10 to 15 per cent of antipsychotic prescribing that’s great. Some homes will be able to do it. Can you do that and not have a significant increase in violence, assaults against other residents, worsening behaviour and an increase in distress for patients? That’s the challenge," Seitz said.
With considerable effort on an institution’s part, a "reasonable, sustainable target" would be more like 20 per cent, said Seitz, who divides his time between patient care and a professorship at Queen’s University in Kingston.
He said most nursing homes are probably not staffed at a level that would be ideal for managing aggressive behaviours without drug use, although they do a good job with the staffing levels their budgets allow. Some residents respond well to one-on-one activities, he added.
"I think we would certainly see some individuals may not need be on antipsychotics if they were given access of that one-on-one support," Seitz said.
Meanwhile, he said the public should not be unduly alarmed by some of the medical risks that have been sounded over the use of antipsychotic drugs.
Studies have linked the use of these medications to increased risk of falls and fractures, stroke and sudden cardiac death.
Seitz said for every five or 10 persons with psychosis or who show significant aggression associated with dementia, one will experience a very noticeable improvement in behaviour when prescribed antipsychotic drugs while others will see a lesser improvement.
But when it comes to added medical risks from taking antipsychotics, the increase in stroke or mortality, for example, is more along the order of one in 100, he said.
"Statistically and clinically, you’re much more likely to actually have a significant benefit from the medication than suffer one of these adverse events," Seitz said.
Trish Rawsthorne visits her mother and sister, Linda Liberta, 73, at Misericordia Place, one of the city’s newer and larger personal care homes, about three times a week.
She said it’s apparent that staffing is inadequate to meet all of the residents’ basic needs.
"The staff are caring people. My complaints are never against the staff," Rawsthorne emphasized as she escorted a reporter on a visit to her family members.
Yet, she’s critical of the institutional atmosphere of the personal care home, where residents are cared for under a strict clock, the nursing home’s clock.
"Generally, they get you up in the morning and get you washed as quickly as possible. If you object to being rousted out of bed they leave you and go to the next one," Rawsthorne said.
Meals are served at specific times whether residents are hungry or not.
Most residents are in diapers, whether they need to be or not, because there is nobody there to help them go to the bathroom when they need to, she said.
Rawsthorne said nursing homes should be home-like environments, not run like institutions. That is especially important for those coping with dementia. "Their perception is already screwed up enough," she said of the elderly residents.
She’s found to her dismay that her sister’s teeth are not brushed, which was confirmed by a dentist, unless she does it herself and that both her sister and her mom have had their toenails grow to the point where it has affected their mobility. She now has a certified pediatrist come in regularly to look after her mom’s nails, while she does her sister’s.
Also concerning, Rawthorne said, she discovered last fall that her sister was not always receiving medication that reduces her anxiety.
Caroline DeKeyster, chief nursing officer with Misericordia Health Centre, rejected the allegation that Misericordia Place operated more like an institution than a place where residents are treated as individuals. "All the care, from my view, that is provided is on an individual basis. We look at each person as what their need is," she said.
DeKeyster said that teeth brushing can be missed if a resident is sleeping. "Oral care is something that is optimally done. We’re doing it twice a day, of course. There will be always times when there are exceptions to that… We’re not going to wake somebody up to do oral care if they’ve already gone to sleep, for instance."
She said the personal care home is not understaffed and rejected any links between staffing levels and the use of antipsychotic drugs there. Use of antipsychotics at Misericordia Place is slightly above the Winnipeg average.
"The expectation for us and the important aspects of the way we provide care is based on the individual needs," DeKeyster said. "We document based on assessment and science, not based on a formula."
Larry Kusch didn’t know what he wanted to do with his life until he attended a high school newspaper editor’s workshop in Regina in the summer of 1969 and listened to a university student speak glowingly about the journalism program at Carleton University in Ottawa.