Commissioner wants pharmacists involved

elderly couple silhouette made from pills

Following the commencement of the Royal Commission into Aged Care, one key stakeholder has spoken of “extreme” concern over chemical restraint

Aged Care Quality and Safety Commissioner Ms Janet Anderson has issued a statement saying that “because of the potential risks posed to the safety, health and wellbeing of aged care consumers, restrictive practices are given careful attention by Commission staff when assessing a provider’s compliance with the Quality Standards and investigating complaints about aged care providers”.

Ms Anderson said that the Commission schedules “regular unannounced visits based on complaints data and other intelligence, including any information about inappropriate use of restraints”.

“The Commission is extremely concerned if any aged care consumer is being inappropriately restrained, either through physical means such as the use of a belt, or chemical means such as by using antipsychotic medication,” the statement says.

“The Commission requires all residential aged care services to demonstrate that alternative strategies are used to manage challenging behaviours.

“Where absolutely necessary and therapeutically indicated, use of restraints such as antipsychotic medications must be a last resort and for as little time as possible, consistent with best practice guidance.”

She said that recent “questions and concerns” around the use of restraints has further sharpened the Commission’s interest in this area.

“Service providers can now expect that we will specifically ask them about their restrictive practices when we visit a service. They should be able to point to genuine and sustained efforts to use alternative strategies, and also have in place an effective oversight system for any form of restraint in use for any resident.

“In terms of the required oversight system, my assessment teams are looking for evidence such as the presence of informed consent from the consumer or a properly authorised person.

“We want to see that the service is applying best practice in matters such as effective clinical governance, regular review by health professionals, pharmacists, and communication with the general practitioner or geriatrician, and that records are kept of the outcome of these reviews.

“We are also working to raise awareness about the risks of inappropriate use of physical or chemical restraint. In the first instance, I have asked the Commission’s interim Chief Clinical Advisor to identify information that can help providers to focus on the actions needed to improve their practices and support better outcomes for all consumers.

“We are also highlighting this issue through a case study in our upcoming Better Practice Series: Preparing for the new Standards which commences in February 2019,” Ms Anderson said.

Her comments follow those last week of Minister for Senior Australians and Aged Care Ken Wyatt, who said that incidents of over use of physical and chemical restraint will not be tolerated and draft changes to regulations are expected to be released within weeks.

“The use of antipsychotic medicines must be a clinical decision made by medical practitioners with the care recipient, and their carer or family involved at all times,” Mr Wyatt said.

“The Department of Health has provided all aged care homes with the Guiding principles for medication management in residential aged care facilities to assist managers and staff to practice quality use and safe management of medicines.

“The Department has also provided the Decision-Making Tool Kit – Supporting a restraint free environment in Residential Aged Care to residential aged care homes.

“The toolkit emphasises that a restraint-free environment is a basic human right for all care recipients and chemical restraint, such as antipsychotics, should not be implemented until all alternatives are explored.”

Last week, the ABC’s 7.30 reported on fresh allegations of physical and chemical restraint, particularly via antipsychotics.

Pharmacist and Senior Lecturer, Wicking Dementia Research and Education Centre, University of Tasmania Dr Juanita Westbury wrote on the AJP website in response that benzodiazepines also need to be a focus.

“It’s not just antipsychotics,” she wrote. “Benzodiazepines are now being used instead of antipsychotics- prevalence in aged care is rising. If you restrict one class the use of substitutes will occur. Pick your poison.

“It’s not just in people with dementia either. Both antipsychotics and benzodiazepines are being given to people who are agitated, calling out for attention and anxious. Older people without dementia have these symptoms too.

“Pharmacists should provide education as QUM about these drugs, do audits and recommend monitoring for effect and adverse effects. Deprescribing is the key.”

Dr Westbury also told the AJP that the use of benzodiazepines in aged care is rising – especially those charted on the ‘prn’ list (nearly a third of residents).

She and colleagues have recently published work on the need to improve psychotropic prescribing here.

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