Psychotropic medications used as restraint

First published 26 March 2014, I felt this was worthy of blogging about again as a reminder to us all, as only yesterday heard from a clinician in aged care it was ok to use them.

Up to 80% of people with dementia and nearly half of people in residential aged care facilities are receiving psychotropic medications that in some cases are inappropriately prescribed, a report released today by Alzheimer’s Australia has revealed.

The report, The Use of Restraint and Psychotropic Medication in People with Dementia, provides an evidence-based review of the prevalence of the use of restraint, and the potential negative consequences and legal issues surrounding the use of psychotropic medication and physical restraints in people with dementia.

Ita Buttrose, who was then the National President of Alzheimer’s Australia, said that the report raises concerns that in many cases psychotropic medications and physical restraints are the first line of response to the challenging behavioural and psychological symptoms of dementia (BPSD).

“International data suggests that only 1 in 5 people with dementia receive any clinical benefit from these medications,” Ms Buttrose said.

“We must ensure that the basic rights of a person with dementia are respected. Clinical guidelines indicate that psychosocial approaches should be considered first, including person-centred care and recreational therapies,” Ms Buttrose said.

The key points of the report at a glance:

Physical Restraint
• The prevalence of physical restraint in aged care facilities varies and evidence suggests prevalence ranges from 12–49%.
• 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.
• There are some situations in which it may be appropriate to use physical restraint for a short period of time, but clinical guidelines indicate that physical restraints should always be an intervention of last resort.
• There are a wide range of environmental, strength-promoting, surveillance and activity-based alternatives to using restraints.
• It is best practice to ensure that consultation takes place with the carer and/or legal representative prior to the decision to apply restraint. In an emergency situation this may not be possible immediately but should be done as soon as possible. Jurisdictional variations in guardianship legislation govern the roles of proxy decision-makers in giving consent to restraint on behalf of people unable to give informed consent themselves.

Psychotropic Medications
• About half of people in residential aged care facilities and up to 80% of those with dementia are receiving psychotropic medications, although this varies between facilities. There is evidence to suggest that in some cases these medications have been prescribed inappropriately.
• BPSD although variable in severity are common and affect almost all people with dementia sometime during their illness. They have a range of physical, environmental and psychosocial causes.
• The evidence supporting the effectiveness of psychotropic medications in treating BPSD is modest at best, with some support for atypical antipsychotics. International data suggests that up to 20% of people with dementia who receive antipsychotic medications derive some benefit from the treatment.
• Psychotropics have a range of serious side effects and are associated with increased mortality for people with dementia.
• Psychotropics are best used where there is severe and complex risk of harm, when symptoms are psychotic in nature, when psychosocial interventions have been exhausted or when there are comorbid pre-existing mental health conditions.
• Experts recommend that psychotropic medications be used for a limited period only, with regular review regarding possible discontinuation at least three-monthly.
• Expert consensus guidelines recommend the use of multidisciplinary, individualised psycho-social approaches as a first line approach to behavioural symptoms of dementia. There are a range of psychosocial and caregiver interventions that have evidence-based support. Best practice for BPSD treatment is comprehensive, individualised assessment in order to provide person-centred care, with family and professional caregiver education and support.
• Informed consent for use of psychotropic medications should be obtained from the person themselves where possible. Alternatively, if the person is unable to give informed consent, then consent should be obtained from a substitute decision-maker.

Key recommendations are also available in the report.

8 thoughts on “Psychotropic medications used as restraint

  1. I was at a talk where Prof. B delivered evidence based reports of the effect of lack of effect of drugs compared to person entered care. Opened my eyes. Part of the solution is the need for more carers who can give time, care, love and meaningful engagement and write about it whether its for the local paper, in-house magazine, on a blog on in academia. Let people know there is a different approach.

    • Prof Brodarty gives an incredible presentation on why NOT to use psychotropics unless it is for a MENTAL illness, dementia is a contraindication of those drugs as far as I recall… and thanks for allowing your eyes to be opened Paul 🙂

  2. Hi Kate,
    Am working with Prof Brodaty on the HALT Project at UNSW. Working with aged care facilities to improve care/reduce the use of anti-psychotics. Facing some opposition from some facilities but getting there!! Hope that it leads to some public health initiatives. Keep up your good work.
    Monica 🙂

  3. There are absolutely better ways for residential aged care to respond to people’s lifestyles, particularly those with Dementia. The real issue for aged care providers is being able to navigate and then enact the best ways. Good providers are able to juggle their finite resources to individualise activities and therefore respond better to each person. The reality is that the aged care environment is a community and often the use of psychotropic drugs relates to people living in that community and being able to respect everyone living there. I am not condoning use but rather emphasize the need for a positive response looking for solutions to a problem which so much more complex than the use of restraint. Thanks Kate for the opportunity to comment!

    • Thanks for your thoughts Megan.. I always wonder, if we drugged our children to modify their challenging behaviours when they were young, we would of course, all be on abuse charges… yet so often it is still being done to our elderly and those living with dementia.

      • 100% agreed!
        I really worry though about where we focus research questions. Right from the beginning of the research we must be looking to how we can implement it rather than expecting it to miraculously change practice. Working in aged care I have been involved in multiple research projects with slightly different focus’s related to psychotropic medication. The challenge is that once the research ends the use starts rising again and the actions are not duplicated across the rest of the industry. The real question is to explore how do we translate the research into practice. The research is not completed when the report is finished and articles are written. We are involved in the RedUSe – reducing the use of sedative medication in aged care facilities with University of Tasmania. Good luck to Monica and the HALT project, hopefully these two pieces of research can work together to make change.

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