• Dementia 2020
  • Dementia 2020

Minimising restraint use

To improve the health and care outcomes for the more than 447,000 Australians living with dementia, there must be a commitment from all stakeholders to dementia education to eliminate overuse of chemical and physical restraint, supported by a national framework for workforce development, writes David Sykes

The Royal Commission into Aged Care Quality and Safety, as well as a wide range of evidence sources, including available data, research studies and feedback from people living with dementia, their families and carers, suggest there continues to be widespread inappropriate use and overuse of chemical and physical restraint. There is an urgent need to provide alternatives.

Australian clinical guidelines recommend that antipsychotics are only prescribed after non-pharmacological approaches have been attempted, however, research shows that the use of antipsychotic medication is only appropriate in about 20% of cases [1].

Antipsychotic medications have a range of serious side effects and are associated with an increased risk of stroke and mortality for people living with dementia [1]. Despite overwhelming evidence that antipsychotics are not effective or safe, they are routinely prescribed and administered against clinical guidelines to people living with dementia often as the primary ‘treatment’ for managing ‘behavioural and psychological symptoms of dementia’.

Physical restraints can have a range of adverse psychological and physical effects. Research has shown that overall physical restraints do not prevent falls and may, in some cases, cause death [1].

Dementia Australia (DA) has been calling for mandatory dementia education, supported by appropriate staffing levels and skills mix to provide a focus on alternatives to minimise the inappropriate and unnecessary use of antipsychotic medications and restraints.

DA’s recommendations in December’s Workforce Submission to the Royal Commission provides practical, implementable steps that focus on building capacity and knowledge of dementia throughout the industry [2].

To build dementia knowledge in the workforce, a national framework that clearly articulates the content and learning outcomes expected at each level needs to be developed. National standards are required to ensure the dementia education provided is high quality and mandated in relevant vocational and tertiary education programs [2].

Applying dementia knowledge needs government and industry support of knowledge translation (KT) activities, including supporting organisations to adopt learning cultures, promoting programs which build coaching and mentoring capability in the aged care workforce and promoting the development of communities of practice [2].

In addition to the dementia KT activities outlined above, it is essential that Dementia Practice Leaders are created. Developing career pathways to enable staff to specialise in dementia, and enabling Dementia Practice Leaders in their organisations to mentor other staff will assist in elevating dementia practice [2].

A strong and sustained focus on leadership and culture as well as practical initiatives that improve the knowledge, skills and capacity of the workforce in issues relating to dementia is vital. This has been the focus of the Centre for Dementia Learning at Dementia Australia for a number of years, through programs such as consultancy and providing a comprehensive suite of education programs including the award-winning Educational Dementia Immersive Experience (EDIE™) workshop; and also through the delivery of the Dementia Essentials program as part of Dementia Training Australia.

Dr David Sykes is Director, Centre for Dementia Learning, Dementia Australia and Director, Dementia Training Australia

Stock image: Adam Nieścioruk on Unsplash.com

A partnership between the person living with dementia, family carers, their treating doctor, pharmacist and other health and aged care professionals is crucial to providing alternatives to the use of antipsychotic medications.

People living with dementia and their care representative should be informed about all prescribed medications, including potential side effects. Consent to prescribe psychotropics should always be obtained from the person living with dementia or their care representative [1].

To ensure there is greater onus on informed consent for the use of antipsychotics and to eliminate inappropriate use, there must be some changes to the authorising environment, specifically to the Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019. Amendments should include building informed consent for the use of antipsychotics into legislation, mandating an administration register which records all usage of chemical restraint, increasing education and awareness amongst consumers, families and aged care staff, and implementing an external authorisation process.

Multidisciplinary care teams must include accredited clinical pharmacists in medication reviews, in what is a highly nuanced and complex area of medicine. Specialist clinical pharmacists are well placed to oversee governance of medication management, particularly for areas of high medication risk and monitoring the use of chemical restraint. They can resolve medication issues, look at interactions of medicines, provide needed follow-up for residents with ongoing issues and evaluate their recommendations.

To improve the health and care outcomes for the more than 447,000 Australians living with dementia, there must be a commitment from all stakeholders to dementia education to eliminate overuse of restraints, supported by a national framework for workforce development.

Dr David Sykes is Director, Centre for Dementia Learning, Dementia Australia and Director, Dementia Training Australia

References

  1. Peisah C, Skladzien E (2014) The Use Of Restraints And Psychotropic Medications In People Living With Dementia. Dementia Australia.
  2. Dementia Australia (2019) Royal Commission into Aged Care Quality and Safety – Workforce Submission. Dementia Australia.

Want to read the other articles in this issue? SUBSCRIBE TODAY for as little as $99 to improve your practice and stay up to date on the latest in dementia research and training.