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Chemical restraint in aged care – we can reduce use

Fred was a resident with Alzheimer’s disease living at one of our aged care homes. He was a quiet man; in fact, Fred had not spoken for years. Like many people with dementia he became agitated and upset, particularly around evening meals. He would refuse to eat at certain times. Two years ago Fred was prescribed a small dose of risperidone, an antipsychotic, to help him settle.

After review Fred was slowly taken off his risperidone. Soon after, Fred mumbled something after an evening meal. The carer, absolutely astonished to hear him speak, asked him to speak up. “I hate soup …..pumpkin soup.”

The carer quickly rung his family to tell them that Fred had spoken. They confirmed he hated pumpkin soup with a passion. Staff recalled that Fred became more agitated at meals where this soup, the cook’s speciality, was served. Being forced to eat food he disliked was probably contributing to his agitation. Taking a heavy sedating drug, along with his dementia, made it difficult for him to tell anyone.

The home pledged to never serve Fred pumpkin soup again.

We frequently heard stories like this when our intervention, RedUSe (Reducing Use of Sedatives), was delivered to 150 aged care homes across Australia from 2014-20161. Few were as dramatic as Fred’s but we often heard staff say that when residents came off sedating medication they became more engaged and less confused. For many, reducing the drugs made little difference to their agitation level or other behaviours. Care staff also told us they felt a sense of achievement when they successfully managed an agitated or anxious resident without resorting to medication.

It is important to acknowledge that some residents do require psychiatric medication with sedating properties (i.e. antipsychotics, benzodiazepines, sedating antidepressants) if they have mental illness such as schizophrenia, bipolar disorder, severe anxiety states and major depression. Further, some people with dementia experience very high levels of distress, hallucinations and/or pose a risk of harm to themselves or others. Prescribing antipsychotics to these residents is justified provided their effectiveness and adverse effects are closely monitored and the lowest effective dose is taken for a time-limited period (usually 3 months)2.

However, when these medications are given to older people with less serious symptoms such as calling out, agitation and wandering, the risks associated with use often outweigh any benefit they may offer. To give an example, about one in five residents with dementia experiencing agitation will benefit from taking antipsychotics, yet taking these medications increases the risk of stroke, pneumonia, death from all causes, cardiac problems, falls, tremor and confusion2.

My own qualitative research, and that of researchers overseas, has found that care staff will often request psychotropic medication from prescribers with the aim of ‘providing comfort’ or ‘to calm’ residents3. Most staff don’t want to ‘dope residents up’ for their own convenience. Many staff and health practitioners also have a strong belief in medication, trusting that these drugs are much more effective than the evidence suggests. When we gave staff a psychiatric drug knowledge quiz we found that most care staff and health practitioners were unaware of their adverse effects4. Few could name a guideline they referred to when prescribing or administering these medications. There is also marked resistance to take residents off sedating medication for fear that behaviours will escalate. Yet, withdrawal studies suggest that most people with less severe symptoms can be taken off these medications successfully with minimal impact on behaviour5.

What does the RedUSe intervention involve? It’s a program lasting 6 months involving awareness raising, education and sedative review. To raise awareness of sedative medication use we audited each home and then compared their use to others. One large Queensland home assured me they didn’t have a problem, only to find that over a third of residents were taking antipsychotics. If you don’t measure or compare use its difficult to assess if use is too high. After, the audit results are provided to staff, along with education on sedative use by trained pharmacists. These sessions aimed to promote discussion by asking if these drugs improved quality of life, provoking some very spirited debates. Finally, a structured review process was conducted where a nurse, pharmacist and GP reviewed all residents at the home taking sedatives1.

Over the past few weeks, when bad news stories about aged care prevail, we found that most aged care staff want to do the right thing – as do the operators. When we approached a large for-profit provider and a not-for profit religious group in Australia to be involved in our intervention they quickly committed to include 50 of their homes, leaving us a target of 100 to recruit. The aged care industry bodies Leading Age Services Australia and Aged & Community Services Australia offered to promote RedUSe in their online magazines. To our surprise (and delight!) we were inundated by homes wanting to participate. Over 330 homes across the country contacted us in the next 4 weeks wanting to take part – a powerful indicator of the willingness of operators and staff to ensure appropriate sedative use.

RedUSe, funded by the Department of Health as a Dementia and Aged Care Service (DACS) fund was provided to 150 Homes from 2014-2016. Over 2500 aged care staff attended training sessions, 300 GPs participated in detailing and over 150 pharmacists were involved in the initiative in six states and the A.C.T.

The project made a significant impact. Overall use of antipsychotics and benzodiazepines was reduced by 13 per cent and 21 per cent, respectively. Of our total sample, two thirds of participant homes reduced the rate of use of both psychiatric drug classes, with 142/150 homes recording a reduction in the use of either class. When residents taking sedative medications at baseline (over 4000 aged care residents) were tracked throughout the 6-month intervention, 40 per cent had their sedative dose reduced, with most having their agent totally ceased. Importantly, the project was well accepted, with 95 per cent of staff ranking the education provided by the project as very good/excellent6.

Unfortunately, the DACS initiatives from 2014-2016, including RedUSe, were not continued, nor are training materials available for use, although we have been informed this is planned7. Interim economic modelling has shown that RedUSe is cost effective through medication cost reductions alone6. Ideally, with appropriate support, the project could be delivered through federally funded community pharmacy as a series of Quality Use of Medicines (QUM) strategies, currently administered through the Pharmacy Guild. The objectives of the QUM Program are to advise members of the home’s healthcare team on medication management issues, provide education to carers and other healthcare providers, and assist homes to undertake continuous improvement activities, including ensuring accreditation standards are met8.

Dr Juanita Westbury is an aged care pharmacist with a passion for ensuring appropriate psychotropic use.

The RedUSe project was recently awarded the 2018 Mental Health Services ‘TheMHS’ award for Training, Education or Workplace Development.

References:

Westbury J, Gee P, Ling T et al. RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Med J Aust 2018; 208(9):398-403. doi: 10.5694/mja17.00857 https://www.mja.com.au/journal/2018/208/9/reduse-reducing-antipsychotic-and-benzodiazepine-prescribing-residential-aged

RANZCP Professional Practice Guideline 10. Antipsychotic medications as a treatment of behavioural and psychological symptoms of dementia. August 2016. https://www.ranzcp.org/Files/Resources/College_Statements/Practice_Guidelines/pg10-pdf.aspx

Janus S, van Manen J, et al. Reasons for (not) discontinuing antipsychotics in dementia. 2018; 18(1):13-20. https://doi.org/10.1111/psyg.12280

Brown D and Westbury J. Assessing Health Practitioner Knowledge of Appropriate Psychotropic Medication Use in Nursing Homes: Validation of the Older Age Psychotropic Quiz. J Gerontol Nurs. 2016;5:1-8. https://www.ncbi.nlm.nih.gov/pubmed/27379454

Van Leeuwen E, Petrovic M, van Driel ML et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD007726. DOI: 10.1002/14651858.CD007726.pub3 https://www.cochrane.org/CD007726/DEMENTIA_stopping-or-continuing-long-term-antipsychotic-drug-use-behavioural-and-psychological-symptoms-older

Wicking Dementia Research and Education Centre. University of Tasmania. RedUSe: Reducing Use of Sedatives in aged care facilities http://www.utas.edu.au/wicking/research/services/RedUSe

Department of Health. Aged Care Service Improvement and Healthy Ageing Grant (ACSIHAG) Program – Key Learnings Document. 20 March 2018 https://agedcare.health.gov.au/funding/dementia-and-aged-care-services-fund-dacs/aged-care-service-improvement-and-healthy-ageing-grant-acsihag-program-key-learnings-document

Department of Health and Pharmacy guild. Residential Medication Management Review programs (RMMR) and Quality Use of Medicines Program (QUM). July 2017 file:///C:/Users/jlw1/Downloads/6CPA_RMMR-QUM-Program-Rules_Jul2017.pdf

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