Chemical restraint rules benefit patients and GPs

Antipsychotic prescribing changes are coming to aged care (just not in the way anyone thought).

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Come 1 July, aged care providers will have new responsibilities relating to chemical restraints – but while GPs aren’t the ones being regulated, these laws will directly affect their work in aged care.

New amendments to the Aged Care Act 1997, specifically division 54-9 and 54-10, residential aged care providers must satisfy several criteria before using a restrictive practice such as chemically restraining a patient with dementia.

The eight criteria which need to be satisfied to use a chemical restraint, or anything like it, include a requirement to show it is a last resort, a requirement to trial and document alternative strategies and a requirement to obtain informed consent from the patient, among others.

The use of antipsychotics as chemical restraints in aged care came into the spotlight earlier this year, with the final report from the Royal Commission into Aged Care Quality and Safety finding that approximately 20% of residential aged care patients were prescribed the drugs.

The commissioners made a recommendation to only allow geriatricians and psychologists to prescribe the medications.

In its response to the report, the government accepted this recommendation in principle, but ultimately left the decision to the Pharmaceutical Benefits Advisory Committee.

However, given the additional requirements in the proposed amendments to the Aged Care Act, prescribing antipsychotics will become more complex regardless of the PBAC’s decision.

According to Older Persons Advocacy Network CEO Craig Gear, the legislation will empower GPs to give “a bit of professional pushback” if pressured by facility staff to prescribe antipsychotics.

“Obviously, the prescriber needs to see that there has been informed consent, either by the patient or an appointed decision maker,” he told The Medical Republic.

“GPs are really good at that, but often that’s really difficult when they’re working in indirect supervision of the resident themselves.

“They need to understand their roles and responsibilities to ask the questions and make sure that the family, if they’re the substitute decision maker, have actually talked to [the care provider] and have given informed consent.”

Professor Susan Kurrle, a practising geriatrician who was a medical advisor to the Royal Commission and helped draft the amendments in question, said she hoped tighter regulations will encourage GPs to look for underlying causes in distressed patients.

“I think it behoves us all to make sure that a person [with dementia] is having regular paracetamol intermittently, just in case they do have hidden pain that they can’t express,” she told TMR.

According to Professor Kurrle, who works closely with the Dementia Behaviour Management Advisory Service (DBMAS), a significant amount of distress in dementia patients can be put down to untreated pain, constipation or being too cold.

“The good thing about this legislation is that hopefully will make us look a little more broadly at the resident and not just go straight for antipsychotics, because that’s actually not that effective,” she said.

In some instances, however, Professor Kurrle agreed that antipsychotics could offer some benefit – which is why she hopes to see GPs retain the option to prescribe them.

“I actually talked to a lot of GP colleagues, when the idea to limit prescribing was mooted, and a number of them said that it would really take the pressure off them in terms of having to prescribe something, but it would also leave them powerless,” she said.

“It leaves them without that option, and when someone is climbing up the wall because they’re convinced that there’s foreign soldiers coming through the front door, [prescribing antipsychotics is very appropriate solution].”

Professor Kurrle also acknowledged that the amendments weren’t a complete fix-all, and that some people with dementia may not be accepted into the care facility of their choice due to their condition.

In cases where GPs were unsure how to proceed, she also recommended ringing DBMAS “partly to pass the buck, but also to get some expert advice”.

“The other positive thing is, if the person really does have problems that are very, very hard to address, then the DBMAS has an arm called the severe behavioural response team, and they basically organise admissions to specialist 10-bed units areas across Australia,” Professor Kurrle said.

“And that’s where people who really cannot be managed in a standard residential aged care facility can go to be managed, and on the whole they do quite well.”

Although the amendments are still before the House of Representatives, a Department of Healthspokesperson confirmed with TMR that they are still expected to commence July 1, 2021.