Chemical restraint recommendation could lead to “substitution” of other drugs: royal commission

View portrait of Senior woman in living room sleeping on sofa at time of COVID-19

The royal commission’s proposed changes to the use of chemical restraint in aged care are mostly positive, but making it much harder to obtain prescriptions for antipsychotics could have unintended consequences, such as pushing residents onto other powerful medications, says a highly experienced aged care pharmacist.

The commissioners have recommended that as soon as 1 November 2021, only a psychiatrist or geriatrician will be able to “initially prescribe” antipsychotics for aged care residents (recommendation 61).

After that initial decision, GPs will be able to issue repeat prescriptions.

Associate professor at the University of Tasmania and consultant pharmacist to the Aged Care Quality and Safety Commission, Juanita Breen, told HelloCare she understands the decision. “They obviously want to restrict use and they want to make antipsychotics harder to get, because at the moment it’s very easy, a GP can just prescribe it,” she said.

But Breen said the overseas experience has shown, especially in the US, that when you place restrictions on one group of medications, a “workaround” solution is often found in the form of substitution.

Sedatives can leave residents “slumped in a chair”

“If this recommendation is taken up, [antipsychotics] are going to be very hard to get,” Breen said.

If the recommendation is taken up, what happens in an aged care home when a resident becomes very distressed or is really at risk of harm, Breen asked?

She said the idea of being able to contact an on-call psychiatrist was laughable.

What will often happen is other sedating medications that are less studied and less usually prescribed in aged care – such as oxazepam, benzodiazepine or gabapentin – will be given.

Antipsychotics are the most studied of the drugs usually applied in these circumstances, risperidone in particular, says Breen. 

The risks with all sedatives include increased risk of falls, increased risk of pneumonia, worsening of other health conditions, but “the main thing”, Breen says, is the resident “isn’t able to engage as much as they can, because they’re slumped in a chair”.

Sedatives sometimes necessary

However, some aged care residents need medication “for a short period of time” if a resident is “acutely distressed or hurting themselves or other people”, Breen explained.

The commissioners have also recommended that restraints be used only as a last resort (recommendation 17), to prevent serious harm and after alternative strategies have been used, to the extent necessary, proportionate to the risk of harm, and for the shortest time possible.

Regulation in this area has already been beefed up by the government, but these latest recommendations represent a “tightening”, Breen said.

Consent is also a key component of prescribing antipsychotic medication (recommendation 17).

More staff, better training will help staff calm distressed residents 

Having more staff (recommendation 75) and better training (recommendations 78, 79, 80, 81) for aged care workers – key planks of the royal commissioner’s final recommendations – will help staff better identify the underlying causes of distress, Breen told HelloCare.

When a resident becomes really distressed, rather than turning to medication, staff should try to determine the underlying causes of the distress, such as pain, infection, if they are too hot or too cold, if they are bored, or thirsty.

And staff should always talk to relatives too to see if they might understand what is causing the distress.

“Higher staff levels and higher qualifications of the staff, that comes out loud and strong [in the recommendations]. I think all those things will act to lessen the need to restrain people,” said Breen.

“You can’t just say ‘you can’t have these medications’ or make them really difficult to use, and then not have alternatives or not have trained staff who can work out other ways of managing this behaviour.”

“The training recommended is really, really needed,” Breen said.

Fines, compensation for breaches

Breen also supports the recommendation to penalise breaches of the recommended chemical restraint regulations with civil penalties and the ability to claim compensation (recommendation 17).

Improvements already observed

Breen told HelloCare that when she first began looking into medication use in residential aged care, there wasn’t a great deal of awareness of antipsychotic use. But that has changed in recent years, and the attention the topic has received has already contributed to more responsible use of drugs in aged care homes.

“When I started, people really didn’t appreciate how much it was used. Now it’s a topic that people know about and that people ask about,” Breen said.

In recent visits, Breen says she is seeing “much less use, especially of antipsychotics.”

“That’s really good,” she said.

Better monitoring will also help

The recommendation that restraint use is monitored and reviewed (recommendation 17) is also a positive, Breen noted. “That couldn’t come soon enough because you don’t know if you have a problem if you don’t measure it.”

New quality indicators on the use of antipsychotic medications, due to come in this July, will also help.

Regulator just getting going

As for the recommendation to abolish the Aged Care Quality and Safety Commission, where Breen has been working for “a short period of time”, “there’s a very strong will to help [at the commission], to redress some of the inadequacies that have been found,” she said. 

“It’s only been in existence as it is for two years and starting something up from scratch could delay much-needed reforms. I feel like they’re almost just getting going.”

Overall, the royal commissioner’s recommendations around chemical restraint are “all good”, but Breen just issues a word of caution about making access to antipsychotics “really heavily restricted”. 

“I’m just wondering if that will push a move to alternatives,” she said. “That’s my main concern.”

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  1. As a last resort? Heard that before numerous times it means nothing. Just to make the lazy peoples job easier. I know people that are nearly sedated every night for no good reasons but just to make someone job easy. Would happen a lot.

  2. I wondered exactly the same thing as it will likely have the reverse affect of more frequent transfers to hospital as getting geriatric or psychiatric review in a timely manner is impossible. As an NP who assists many GPs to manage their caseload we are often asked to admit respite clients who become delirious just due to change in environment. We seem to have been excluded completely from the plan

  3. This is not a simple subject. Although restrictions are well intentioned the use of antipsychotics and benzodiazepines have a place. The problem is that often untrained staff are giving these medications and abuse PRN ( as needed) orders.
    More staffing and training in the management of behaviors of concern, agitation, delirium and dementia would be a better solution. There should be a senior registered nurse on duty at all times.

  4. Breen is correct in all comments and debates of use of say risperidone. I have worked in high care dementia for 12 yes and worked in 2 different facilities. One was in a tiny country town and was private, and currently in a small city working in public. Massive difference in residents and behaviours, but this could be contributed to the fact on environment. The private facility is well in advanced to the public in my eyes, which contributes to behaviour management. Staff skill mix a big factor and yes, having the right nurse to resident ratio is a major factor in behaviour management. We currently have always needed to justify the use of PRN anti psychotics one you have exhausted all other interventions, but by that time the resident could be extremely distressed or physically aggressive that there’s is no way of giving the medication. If you know the resident well enough you can gauge the change in behaviour and are able to administer the PRN before it escalates. This all comes down with training in medication and dementia, which i not taught in nursing properly.

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