Restraints & psychotropic medications

Dr Juanita Breen, (previously Westbury) Senior Lecturer in Dementia Studies

ACSA TAS Leadership, Quality & Transformation Symposium 11th November, 2019 Wrestpoint

Mental health in Aged Care Homes

“nursing homes are the modern mental institutions for the elderly”1

1.Rovner B, Katz I. Psychiatric disorders in the nursing home: A selective review of studies related to clinical care. Int J Geriatr Psychiatry 1993;8(1):75-87

“The prevalence of diagnosable psychiatric disorders has been estimated to be 80% or higher. The most common of these disorders are the dementias…” 1

The prevalence of mental health conditions in Australian long term aged care is estimated to be:

Mental health in Australian aged care homes

mental health disorders 86%1

depression 49%1

sleep disorder 45-60%2

anxiety 35%2

dementia 52%1

1. Australian Institute of Health and Welfare (AIHW) 2019. GEN fact sheet 2017–18: People’s care needs in aged care. Canberra. https://www.gen-agedcaredata.gov.au2. Brodaty H et al. (2001) Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 2001;16:504-12.

‘Good Practice’ to manage changed behaviourin dementia, anxiety and insomnia• Assess and manage other causes (e.g. pain,

infection, meds, environment, history……)

• Use non-drug measures first

Another way to manage these symptoms …..restraining physically

A physical restraint is anything near or on the body which restrictsmovement. Such as:

• Lap straps, belts, deep chairs, bean bags, vests or trays, which keepthe body immobile• Bed rails or belts, which keep people confined to their beds, and• Door alarms or locked doors which prevent people from walkingbeyond a set point

What is the problem with restraint?

From childhood on, one of the most important impulses isto maintain independence through movement.

As people age, their ability to move is compromised. For many people who live inaged care homes, it was thought for many years that using "restraints"– devicesthat prevent people from moving around — would ensure safety from falls, otherdangers and protect residents, other residents and staff.

“Evidence suggests that the prevalence of physical restraint in agedcare is between 12–49 per cent” (Alzheimer’s Australia 2014).1

Today, physical restraints are used much less frequently because studies haveshown they can be dangerous.

1. Alzheimer’s Australia.(2014). The use of restraints and psychotropic medications in people with dementia. Position paper 38

Adverse effects of physical restraintPossible physical effects of the inability to move freely include:

• Decreased bone/muscle strength • Decreased appetite and malnutrition• Dehydration• Pneumonia• Urinary tract infections• Constipation• Incontinence• Pressure sores and/or bruising• Death by asphyxiation

Possible mental or emotional effects of using restraints include:

• Agitation• Depression/withdrawal• Loss of dignity• Sleeping problems• Humiliation

What can be used instead?Things an aged care home can do instead of physical restraint include:

• Reducing the risk of falls and injury by using equipment such as low beds, non-slip mats and hip protectors

• Educating families and staff about behavioural and psychological symptoms• Increasing the safety of the home, such as secure environments to allow safe

wandering, or making sure the home is well lit• Increasing staff levels and direct care staff• Promoting light exercise and social activities• Taking care of needs such as poor eyesight and mental health, or problems such

as poor balance or unstable blood pressure.

Another way to manage these symptoms …..psychotropic medications

1. Farlex Partner Medical Dictionary. (2012). Retrieved June 6 2018 from https://medical-dictionary.thefreedictionary.com/psychotropic

Which are medications ‘capable of affecting the mind, emotions andbehaviour’ and are ‘intended to treat mental illness’.1

AntipsychoticsAnxiolyticsHypnoticsMood stabilisersAntidepressants

Cholinesterase inhibitors?Opioids?

Sedative: A medication that has a soothing, calming or tranquillizing effect

AntipsychoticsRisperidone, quetiapine, olanzapine,

haloperidol

benzodiazepines(hypnotics/anxiolytics)

diazepam, oxazepam, temazepam, lorazepam, nitazepam

sedating medications…

Adverse effects of psychotropic medications

20% of people with aggression in dementia will benefit taking

antipsychoticsSedation & Cognition worsens

Benzodiazepine effective for anxiety/sleep only for up to 4

weeks Increased falls risk

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chemical restraint

1. Australian Government, Federal Register of Legislation. Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019. Available at: https://www.legislation.gov.au/Details/F2019L00511/Explanatory%20Statement/Text 2. Center for Medicare Advocacy. Antipsychotic Drugs. Available at: http://www.waombudsman.org/files/2013/09/medicareadvocacy.org-Antipsychotic_Drugs.pdf

‘Chemical restraint is defined as restraint that is, or that involves, the use of medication for the purpose of influencing a person’s behaviour.

However, it does not include medication prescribed for the treatment of:

· a diagnosed mental disorder;· a physical illness;· a physical condition.1

In the U.S.A. the definition is: ‘any drug that is used for discipline or convenience’.2

Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019.

A restraint-free environment is a basic human right for all consumersand restraint should not be implemented unless alternatives areexplored. Any decision to restrain a consumer carries significantethical and legal responsibilities.1

1. Australian Government, Federal Register of Legislation. Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019. Available at: https://www.legislation.gov.au/Details/F2019L00511/Explanatory%20Statement/Text

‘Good Practice’ to manage changed behaviourin dementia, anxiety and insomnia• Assess and manage other causes (e.g. pain, infection, meds)

• Use non-drug measures first

• Antipsychotics are indicated for changed behaviours if they cause significant distress, or pose a safety risk.

• Benzodiazepines are indicated short-term for severe anxiety (4 weeks) or severe insomnia (maximum of 2 weeks).

• Long term anxiety should be treated with antidepressants

• Non-pharmacological strategies should be continued

• When these drugs are prescribed, they should be monitored regularly for effectiveness and adverse effects, whilst using the lowest effective dose for the shortest period of time.

RANZCP – Practice Paper 10, BPSD, 2016RACGP – Benzodiazepines, 2015

How often is psychotropic medication used?

1. Westbury J et al. (2018) “RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities”, MJA, 208(9);398-403.

Sample1

N = 143 LTC homes (11,572 residents)

Collected 3/14-10/15

Data mined from prescribing/packing programsValidated first by a trained nurse and then by research staff

High, inappropriate and extended duration of use reported - 1995 (Snowdon, MJA, 1997)- NSW taskforce, 5 senate enquiries, 1 Royal Commission, 2 ministerial round tables- Dedicated funding for 2 interventions through Dementia and Aged Care (DACS) fund 2013- DBMAS and Severe behavioural response team funding 2014/5. DTA education 2016-2019

Prevalence of psychotropic prescribing in aged care

22% daily 22% daily

11% prn

31% prn

41% daily

7% both

14% both

0.1% prn0.0

10.0

20.0

30.0

40.0

50.0

antipsychotics benzodiazepines antidepressants

Pro

po

rtio

n o

f re

sid

ents

(%

)

Psychotropic prescribing by class

Total no of homes: 143Sample audited 03/14 – 10/15Total no. residents: 11,572

Prevalence of antipsychotic prescribing: other studies

Westaway K, Sluggett J, Alderman C et al. (2018) The extent of antipsychotic use in Australian RACFs and interventions shown to be effective. Dementia. doi: 10.1177/1471301218795792.

% o

f residen

ts

Variation in psychotropic prescribing rates

N = 150 LTC homesn = approx. 12,500 residentsData collected Mar 2014 – Oct 2015

7%

43%

Prn psychotropic medication

1. Randle J et al. (2019) Intermittent antipsychotic medication and mortality in institutionalized older adults: a scoping review. Int J GetriatrPsychiatry 34:906-20.2. Vaismoradi M et al. (2018) Patent safety and prn prescription and administration: A systematic review. Pharmacy 6,95; doi:10.3390/pharmacy6030095

An acronym from the Latin ‘pro re nata’: for ‘an occasion that has arisen’1

A prn prescription authorises administration of a medicine when needed, in theopinion of the nurse/staff administering medications. Dosing can be specified orentirely at the discretion of the person administering the medication.2

Prn psychotropic medication

1. Randle J et al. (2019) Intermittent antipsychotic medication and mortality in institutionalized older adults: a scoping review. Int J GetriatrPsychiatry 34:906-20.2. Vaismoradi M et al. (2018) Patent safety and prn prescription and administration: A systematic review. Pharmacy 6,95; doi:10.3390/pharmacy60300953. Dorks M et al. (2016) prn medication in nursing homes: the longer you stay, the more you get? Eur J Clin Pharmacol 72:995-1001

• Allows intermittent dosing1,2

• Caters to individual requirements2

• No direct physician supervision2

• Increased decision making of staff2

• Dose sparing?

• Can lead to excessive use 1-3

• Can lead to drug interactions2

• Prn benzodiazepine use linked to increased risk of falls2

• Prn antipsychotic use linked to increased mortality risk1

• Used as first resort for BPSD?1

• Who is making the decision to use? 1-3

A case in point1

1. Coroners Court, Melbourne, Victoria: COR 2015 available from; 1527https://www.coronerscourt.vic.gov.au/sites/default/files/2019-02/MargaretBarton_152715.pdf

Mrs Margaret Barton (83yrs) medical history - Alzheimer’s disease, heart disease,osteopenia (multiple fractures). She was admitted for respite care late January 2015and was transferred to a permanent place in another home in late Feb 2015.- Respite home reported Mrs Barton as being ‘confused and paranoid’, with ‘significant

behavioural issues’ (anxious, wandering, verbally aggressive, resistive to care)- GP prescribed ‘prn’ oxazepam 7.5-15mg bd. Staff administered oxazepam at least daily

(15mg) for 16 days. GP then prescribed regular oxazepam 15mg tds & ceased ‘prn’ dosing.- Mrs B sustained 3 falls in the next week.- Transferred to the new permanent home 28th Feb, along with her medication chart.- Oxazepam 15mg tds but original ‘prn’ order was copied over. Additional doses were given

(combined dose was 90mg/day for 2 days).- Mrs B sustained 7 falls over the next week. Behaviours listed as ‘significant and persistent’.- By mid-March regular oxazepam was ceased, with ‘prn’ dosing of olanzapine, paracetamol,

oxycodone and oxazepam charted. All four medications were given twice daily.- Mrs B was admitted to hospital 20th March. Delirium was diagnosed. A CT scan identified 3

rib, 2 vertebral and a pelvic fracture.- Mrs B died 29th March.

- Post mortem revealed additional rib fractures and consequent pneumonia.

Home identifier number

% o

f residen

ts

Variation in prn prescribing rates

N = 143 Aged Care homesn = 11,572 residentsData collected Mar 2014 – Oct 2015

Benzodiazepine prn charting

2%

67%

The intervention

• Audit, benchmarking and feedback of antipsychotic & benzodiazepine use at baseline, 3 months and 6 months

• Education at baseline and 3 months

• Inter-disciplinary review (nurse, GP, pharmacist) after education session

What can be done?

Method: Multi-strategic, inter-disciplinary 6-month intervention

Controlled pilot trial of 25 homes in Tasmania 2008

Expanded to 150 homes across Australia in 2014-15

25

The RedUSe educational sessions

The educational sessions of RedUSe were primarily targeted at

nursing staff and carers and designed to:

• Provide education that challenged beliefs around psychotropic

effectiveness,

• Include information about their risks,

• Promote current guidelines

• Personalise and compare their own data

• Delivered by their own pharmacist at the

beginning of the project and then again at 3 months

Westbury, JL et al. “RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities”, Medical Journal of Australia, 2018 208 (9) 398-403.

Beliefs of staff around psychotropic medication

Many staff believe that these medications are more beneficial than research suggests. They often stated that they felt psychotropics improved residents’ quality of life and that they were needed to ‘calm and comfort’ them.

“It may not be nice to medicate somebody but surely its far nicer to have them medicated and calm than distressed. On the whole they have a positive impact on their life.” EN

Aged care staff were often not aware of side effects associated with use, often attributing adverse effects of falling, drowsiness or movement effects as related to being old.

From Holland…Doctors, nurses, and family caregivers generally consider the benefits of antipsychotics to outweigh the risk of side effects. The main reasons to start therapy are agitation and aggression.

The estimated success rate in the discussed cases among doctors was 50%, nurses reported 53%, and relatives 55%. The most frequently expected adverse reactions were increased fall risk and sedation.1

1. Cornege-Blokland E et al. (2012). Reasons to Prescribe Antipsychotics for the

Behavioral Symptoms of Dementia: A Survey in Dutch Nursing Homes Among

Physicians, Nurses, and Family Caregivers. JAMDA 13(1) 80.e1-80.e6

Overall antipsychotic prevalence of use during RedUSe

Baseline, 21.6

3 months, 19.7

6 months, 18.8

15

16

17

18

19

20

21

22

23

Baseline 3 months 6 months

Per

cen

tage

of

resi

den

ts

antipsychotics

Reduction: antipsychotics: 13%

N = 150 homesn = 12,165 residents (av)

AP use reduced from 21.6% to 18.8% at 6 M. These differences were significant (p <.001).

Overall benzodiazepine prevalence of use during RedUSe

Baseline, 22.3

3 months, 19.6

6 months, 17.6

15

16

17

18

19

20

21

22

23

24

Baseline 3 months 6 months

Per

cen

tage

of

resi

den

ts

benzodiazepines

Reduction: benzodiazepines: 21%

N = 150 homesn = 12,165 residents (av)

Use reduced from 22.3% to 17.6% at 6 M. These differences were significant (p <.001).

Aged Care Home response rate across the RedUSe intervention

0 20 40 60 80 100 120 140 160

Number of homes

reduced both antipsychotics and benzodiazepines

reduced one sedative

no reduction recorded

66% 29%

5%

Westbury, JL et al. “RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities”, Medical Journal of Australia, 2018 208 (9) 398-403.

Excuses not to RedUSe

30

1. Doctors write the scripts2. Nurses pressure us to3. Not enough staff4. Residents will all ‘go off’5. It’s only a small dose6. You have no idea what it’s like to work with them.7. Side effects are ‘overblown’8. If they make them die earlier, is that such a bad thing?

Acknowledgements

The RedUSe project was funded by the Australian Government under the Aged Care Improvement and Healthy Ageing Grant Fund,

now known as the Dementia and Aged Care Service Fund

NHMRC

ACSA, LASA, NPSMedicinewise, DATIS and the PSA

THANK YOU

http://www.utas.edu.au/wickingDr Juanita Breen PhD, MSc, BPharm

Senior Lecturer in Dementia Studies

Wicking Dementia Research and Education Centre

Email: Juanita.breen@utas.edu.au

Wicking Dementia Research & Education Centre

©University of Tasmania 2019Unless otherwise stated, this presentation and all content within it is the property of the

University of Tasmania and is protected by copyright and other intellectual property laws.

Wicking Dementia Research & Education Centre