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August 2, 2021

The COVID-19 Pandemic and Drug Prescribing in Ontario Nursing Homes—From Confinement Syndrome to Unconfined Prescribing

Author Affiliations
  • 1Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
  • 2Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 3Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Ontario, Canada
JAMA Netw Open. 2021;4(8):e2119028. doi:10.1001/jamanetworkopen.2021.19028

The pharmacoepidemiologic study by Campitelli et al1 examined changes in medication prescribing in nursing homes in Ontario, Canada, during the first wave of the COVID-19 pandemic. The study used linked health administrative databases and an interrupted time series analysis to investigate the weekly proportion of nursing home residents dispensed antipsychotics, benzodiazepines, and antidepressants (psychotropic medications) as well as anticonvulsants, opioids, antibiotics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme (ACE) inhibitors between March 2017 and September 2020. The authors reported that in a cohort of more than 75 000 residents, the COVID-19 pandemic was associated with a small but statistically significant increase in prescriptions for psychotropic, anticonvulsant, and opioid medications but no changes in the prescribing of antibiotics, ACE inhibitors, or ARBs. The short-term increase in prescribing of these potentially inappropriate medications with known harms is concerning, especially given that the conditions that nursing home residents were living under during the pandemic may have resulted in these changes.

Like many jurisdictions across the world, nursing homes in Canada’s most populous province of Ontario were the epicenter of the COVID-19 pandemic before widespread vaccination. Ontario has 626 nursing homes that house nearly 80 000 residents under a publicly funded long-term care program. To date, more than 15 000 Ontario nursing home residents have been diagnosed with SARS-CoV-2, with nearly 4000 COVID-19 deaths.2

At the onset of the pandemic in March 2020, Ontario’s nursing homes enacted measures to prevent the spread of SARS-CoV-2, including blanket no-visitor policies, stopping all congregate dining and social activities, and restricting all nonessential absences from homes.3 These restrictions effectively eliminated in-person interactions between residents and their loved ones as well as the ability of family and friend caregivers to continue providing a substantial amount of direct and often complex care to residents. The restrictions placed on nursing homes lasted for months and resulted in severe and often irreversible physical, functional, cognitive, and mental health declines among residents, a condition now termed confinement syndrome.4

While the direct health impacts of this prolonged social isolation or confinement syndrome can be difficult to measure at a population level, changes in medication prescribing practices can provide clues about the harms that residents may have experienced. In Ontario, approximately 70% of residents live with dementia, and responsive behaviors that may have otherwise been addressed by nonpharmacologic interventions, such as social engagement, may instead have been treated with psychotropic medications that have long been the target of deprescribing initiatives in nursing homes. Campitelli et al1 report an increase in the prescription of antipsychotics, benzodiazepines, and antidepressants, all psychotropic medications used for behavioral management. These results confirm findings from a recent study5 demonstrating increased prescribing of psychotropic medications in Ontario nursing homes during the first 6 months of the COVID-19 pandemic. The present study expands on these findings by documenting increases in the prescribing of other potentially inappropriate medications, specifically opioids and anticonvulsants.

Psychotropic medications in particular were frequently overprescribed in Ontario prior to the pandemic, but overall rates were decreasing in large part due to quality improvement initiatives to reduce potentially inappropriate prescribing. The observed increases in psychotropic prescribing documented by Campitelli et al1 are concerning, as the COVID-19 pandemic appears to have undone some of these gains. As of May 30, 2021, 97% of Ontario nursing home residents are vaccinated against COVID-19, and homes have started to resume visits, social outings, and congregate activities.6 As nursing homes ease restrictions, renewed efforts to optimize psychotropic prescribing should follow. The emphasis should be on using nonpharmacologic approaches, including multidisciplinary care, music, massage, and touch therapy, which may be more efficacious than pharmacologic interventions for the treatment of behavioral and psychological symptoms of dementia.7 Regulatory bodies should consider instating quality indicators for prescribing, implementing prescriber audit and feedback intervention, and requiring training for staff on the nonpharmacologic management of responsive behaviors. This is especially important now given the influx of new staff in nursing homes both during and in the wake of the COVID-19 pandemic who may not have adequate training on important strategies, such as restorative care and gentle persuasive approaches.

Given the increases in prescribing of multiple potentially inappropriate medications, regular medication review for nursing home residents with physicians, pharmacists, and other members of the care team, including family caregivers, should be implemented, and where these reviews have been ongoing, they should be enhanced. These medication reviews are particularly important after a prolonged period of lockdown, when the risk of potentially inappropriate prescribing is likely to have increased.

The authors1 described some of the study’s limitations, including a lack of information on prescribing indications and an inability to evaluate the association of COVID-19 outbreaks, case rates, and deaths with medication prescribing. Some of the documented changes in medication prescribing, in particular the increases in antipsychotics, benzodiazepines, and opioids, could have occurred as part of the provision of palliative care given the higher than usual number of residents dying during the study period. Given that increases in prescribing persisted beyond March to May 2020—when most residents died of COVID-19 during Ontario’s first wave—it seems likely that increases in prescribing were also related to the adverse impacts associated with prolonged and restrictive public health measures. A sensitivity analysis removing residents receiving end-of-life care or removing specific drugs used almost exclusively in palliative care setting (eg, methotrimeprazine) may have helped address this uncertainty. In addition, data collection for this study ended in September 2020, and it would have been instructive to observe whether increases in prescribing persisted through Ontario’s second wave of COVID-19 (September 1, 2020, to February 28, 2021), when even more nursing home residents died of COVID-19 but the province had policies in place that allowed access to essential family caregivers, including during COVID-19 outbreaks.

The results of this study provide us with an important opportunity to reflect on the consequences of isolating nursing home residents with frailty and cognitive decline and restricting them from visits from loved ones and essential caregivers for their own safety. The pressure of the COVID-19 pandemic has revealed critical vulnerabilities in the long-term care system, including the longstanding devaluation of essential family caregivers. In the wake of this pandemic, long-term care systems must have inviolable safeguards in place that allow residents and their families greater autonomy over decisions that consider the balance of quantity and quality of life.

Given the remarkable efficacy of COVID-19 vaccines as well as the extremely high vaccination coverage among Ontario nursing home residents, we are hopeful that this most recent COVID-19 wave will be our last. In spite of this, infectious disease outbreaks, such as influenza, are likely to be long-standing features of life in congregate care settings. We must ensure that older adults living in nursing homes always have access to their caregivers and never again remove all opportunities for this life-sustaining emotional connection and direct care.

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Article Information

Published: August 2, 2021. doi:10.1001/jamanetworkopen.2021.19028

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Reppas-Rindlisbacher C et al. JAMA Network Open.

Corresponding Author: Nathan M. Stall, MD, Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, 600 University Ave, Ste 475, Toronto, ON M5G 1X5, Canada (nathan.stall@sinaihealth.ca).

Conflict of Interest Disclosures: Dr Reppas-Rindlisbacher reported receiving support from the Department of Medicine’s Eliot Phillipson Clinician-Scientist Training Program and the Clinician Investigator Program at the University of Toronto. Drs Rochon and Stall reported having published, having held grant funding, and currently holding grant funding with authors of the study, ie, Michael A. Campitelli, Susan Bronskill, Mina Tadrous, Andrea Gruneir, David B. Hogan, and Colleen J. Maxwell. Dr Rochon reported holding the RTOERO Chair in Geriatric Medicine at the University of Toronto. Dr Stall reported that Susan Bronskill is on his thesis committee and being supported by the Department of Medicine’s Eliot Phillipson Clinician-Scientist Training Program and the Clinician Investigator Program at the University of Toronto and the Vanier Canada Graduate Scholarship.

Campitelli  MA, Bronskill  SE, Maclagan  LC,  et al.  Comparison of medication prescribing before and after the COVID-19 pandemic among nursing home residents in Ontario, Canada.   JAMA Netw Open. 2021;4(8):e2118441. doi:10.1001/jamanetworkopen.2021.18441Google Scholar
The Government of Ontario. How Ontario is responding to COVID-19. Accessed June 14, 2021. https://www.ontario.ca/page/how-ontario-is-responding-covid-19
Canadian Institute for Health Information. The impact of COVID-19 on long-term care in Canada: focus on the first 6 months. March 30, 2021. Accessed June 24, 2021. https://www.cihi.ca/en/long-term-care-and-covid-19-the-first-6-months
Diamantis  S, Noel  C, Tarteret  P, Vignier  N, Gallien  S; Groupe de Recherche et d’Etude des Maladies Infectieuses–Paris Sud-Est (GREMLIN Paris Sud-Est).  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–related deaths in French long-term care facilities: the “confinement disease” is probably more deleterious than the coronavirus disease-2019 (COVID-19) itself.   J Am Med Dir Assoc. 2020;21(7):989-990. doi:10.1016/j.jamda.2020.04.023PubMedGoogle ScholarCrossref
Stall  NM, Zipursky  JS, Rangrej  J,  et al.  Assessment of psychotropic drug prescribing among nursing home residents in Ontario, Canada, during the COVID-19 pandemic.   JAMA Intern Med. 2021;181(6):861-863. doi:10.1001/jamainternmed.2021.0224PubMedGoogle ScholarCrossref
The Government of Ontario News Release. Ontario easing restrictions on long-term care. June 3, 2021. Accessed June 14, 2021. https://news.ontario.ca/en/release/1000258/ontario-easing-restrictions-on-long-term-care
Watt  JA, Goodarzi  Z, Veroniki  AA,  et al.  Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis.   Ann Intern Med. 2019;171(9):633-642. doi:10.7326/M19-0993PubMedGoogle ScholarCrossref
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