Acknowledging the Complexity of Antipsychotic Use in Long-Term Care During the COVID-19 Pandemic

To the Editor,

We are writing in response to the letter titled “The Pre-Emptive Use of Anti-Psychotic Medication in Nursing Homes to Manage Infection Control During the COVID-19 Pandemic: Not That Simple” by Quail. ¹ This letter was in response to our synthesis analysis of Canadian Institute for Health Information (CIHI) data tables identifying the aspects of resident health and quality of care that were most severely affected during the pandemic. ²

We value Dr. Quail’s experience and leadership throughout the challenges posed by the pandemic. We are surprised, however, that our argument was interpreted to suggest that we believe the “pandemic necessitated the increased use of antipsychotics” among long-term care residents. Our intent was to underscore the need for further research that moves beyond what can be gleaned from province-level statistics reported in standardized data tables. We questioned if the increase in potentially inappropriate antipsychotic medications was in response to clinical need, and in doing so, failed to acknowledge the difficulties of implementing non-pharmacological interventions amidst staffing and infection control challenges. We are grateful that Dr. Quail highlighted these important considerations.

The accuracy of our conclusion was also called into question. Specifically, whether the increase in inappropriate antipsychotic medications in 2020/2021 should be ascribed to pandemic exposure, given that an increase in administration also occurred in the previous year among Alberta residents. Our analysis was a comparison of the pandemic period against the 2 most recent historical years and did not test for year-over-year trends. Interrupted time series analysis by Hoben et al ³ supports Dr. Quail’s argument that the inappropriate use of antipsychotic medications increased in the years leading up to the pandemic in Alberta. However, in alignment with our own findings, the rate of that increase accelerated significantly during the pandemic period. We offer supplemental analysis of pairwise comparisons back to 2013/2014 when Alberta was first included in the annual CIHI “Quick Stats” report (Figure 1). This illustrates that (1) the increase during the pandemic period was significant relative to all years since 2014/2015 and (2) the magnitude of the increase observed in recent years was largest during the pandemic period. Without question, a greater percentage of residents received inappropriate antipsychotic medications during the pandemic period.

Figure 1.

Risk ratio statistics comparing the risk-adjusted rate of inappropriate use of antipsychotic medications among long-term care residents in Alberta. All rates obtained from Canadian Institute for Health Information “Profile of Residents in Residential and Hospital-Based Continuing Care ‘Quick Stats’” reports. Values greater than 1.00 and colored in red represent an increase in inappropriate antipsychotic administration relative to the comparison period; values less than 1.00 and colored in green represent a decrease.

Process-oriented health system performance measures distill the complexities of caregiving into simple rates. We will not lose sight of the context offered by Dr. Quail as we work to understand how the pandemic has affected long-term care in Canada.