How pharmacists are reducing chemical restraint

For years it seemed impossible to achieve, but markedly reducing chemical restraint is on its way. AP meets guardians of medicine management who are highly involved.

Australian pharmacists are playing a vital role in one of the nation’s most important healthcare campaigns – the reduction and ultimate elimination of chemical restraint.

The final reports of the Royal Commission into Aged Care Quality and Safety¹ (2021) and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability² (2023) made strong recommendations to reduce and ultimately eliminate the use of chemical restraint, sharing a commitment to upholding the rights and dignity of older people and people with disability.

In a joint statement in 2022, the Australian Commission on Safety and Quality in Health Care, the Aged Care Quality and Safety Commission and the NDIS Safety and Quality Commission acknowledged that psychotropic medicines were being overprescribed and overused for managing behaviours of concern. The disability royal commission final report went even further, says Advanced Practice Pharmacist and University of Western Australia Adjunct Professor Manya Angley FPS.

‘It called for a national approach to reducing and eliminating restrictive practices, including chemical restraint, and emphasised the need for a coordinated framework with targets, data collection, evaluation, performance indicators, timeframes and independent oversight. It also focused,’ she notes, ‘on supported decision-making and workforce training in trauma-informed, person-centred care.’ 

Annual Positive Behaviour Support progress reports were specifically recommended, she says, with an independent evaluation of measures to determine if the use of psychotropic medicines as chemical restraint in people with cognitive disability was reducing.

‘I have been working in aged care as an RMMR and QUM pharmacist since 2018,’ says Dr Angley. ‘Before the aged care royal commission interim report, risperidone as chemical restraint, and psychotropic medicines generally, were used less “mindfully”. If a doctor prescribed a psychotropic medication at usual doses as chemical restraint, it was considered acceptable. Since 2020, GPs, nurses and care staff have greater awareness of the risks of antipsychotics (including falls, stroke and death), the value of bespoke Positive Behaviour Support plans containing a suite of person-centred non-pharmacological strategies, and the need to gain informed consent before using chemical restraint.’

Dr Angley believes ‘everyone is getting better at identifying triggers for changed behaviours’. These can include constipation, urinary retention, pain, boredom, hunger or thirst, infection and medicines.

‘There is improved understanding that chemical restraint should only be used as a last resort, for the shortest possible time and at the lowest dose possible.’

Dr Angley also registered as an NDIS Positive Behaviour Support (PBS) practitioner in 2023. She uses her medicines expertise to identify and deprescribe chemical restraint in NDIS participants.

Pharmacists, as highly trained clinicians, are able to identify if health issues are contributing to changed behaviour. She believes credentialed pharmacists need to play a bigger role in the development of PBS plans for NDIS participants who are prescribed chemical restraint.

There are, however, limited funding options for medicines review services by credentialed pharmacists. Aside from registering as a PBS practitioner, remuneration for services provided to NDIS participants in the community is only available through Home Medicines Reviews, which require a doctor’s referral – a significant barrier.

AP asked two credentialed pharmacists about their experiences with the reduction of chemical restraint.

Case 1

Chelsea Felkai MPS, Disability and ACOP Pharmacist, Maroba Aged Care Facility, Waratah, Newcastle, NSW

I typically generate reports on residents who use psychotropic medicines. I talk with the resident, their family members, the RACF staff who know the resident, and the resident’s prescriber, to look at whether the medicine is the best option for the person, or if we need to explore alternatives.

Once we have established a resident would benefit from reductions, I work with the prescriber to put deprescribing or tapering plans in place to reduce (or cease) less appropriate medicines. Because I am on site 3 days a week, I am able to monitor this closely to ensure the resident is supported and safe through the process.

In early wins, we have been able to replace mostly tricyclic antidepressants (TCAs) with high anticholinergic burden to newer agent antidepressants (I tend to call this low-hanging fruit) with a lot of success.

Though it’s not strictly chemical restraint, it has brought about a large reduction in adverse outcomes across the facility. We have seen a complete cessation of antipsychotic medicines in only two residents so far (the facility has 150, with approximately 25 in the memory support unit), but we have been able to reduce chemical restraint in all residents to the lowest effective maintenance dose.

We have seen an increase in selective serotonin reuptake inhibitor (SSRI) medicines, and a reduction in TCAs. We have also seen an increase in duloxetine and mirtazapine. I have tried to use some of the newer evidence of duloxetine’s efficacy for chronic pain management and mirtazapine’s for sleep support, as options when switching antidepressants.

There has been some discomfort from residents and staff while we have trialled reduction in psychotropic medicines, to ensure the resident is on the lowest possible dose. Because education was provided to staff at the start, it was met with little resistance. And it helped that I was on site to provide support and monitor the outcomes.

Working with the nursing staff to understand when PRN (as required) chemical restraint might be used, and ensuring other options have been exhausted first, has shown the most reduction in how much psychotropic medications have been used so far. The numbers are relatively small, but to be honest, this is largely because the facility had great protocols to begin with.

The impact has been noticeable. Staff members say they feel more confident in the care they provide and the non-pharmacological options they now have at their disposal.

When they do move to a chemical restraint option, it is because other options have been exhausted, and it is in the best interest of the resident.

Case 2

Dr Natalie Soulsby FPS, Credentialed Pharmacist, South Australia

My role is Head of Clinical Governance and Quality Assurance for Embedded Health Solutions, which provides clinical pharmacy services to about 600 residential aged care facilities (RACFs).

One of my roles is to attend national medication advisory committee (MAC) meetings to provide information to head office on medication management, including the psychotropic register. I analyse the information on the register and provide a clinical lens, which is used to support staff to understand where these medicines may be being used as restraints.

The Aged Care Quality and Safety Commission responded to the Royal Commission into Aged Care Quality and Safety by creating a psychotropic register that needs to be updated monthly, so they can keep track of how many patients were prescribed a medicine that was used as a chemical restraint and how they were being managed.

In 2021, when the National Aged Care Quality Indicator Program included the use of antipsychotic medicines, the quarterly numbers showed 21.6% of residents were administered antipsychotic medicines during a 7-day time frame. That figure is now down to 17.3%.

The registers have been a good trigger to remind doctors to review their patients’ treatments. When it began, doctors were concerned about prescribing antipsychotic medicines, and unfortunately some GPs stopped their patients’ medicines, which caused a return of their symptoms. These medicines must be weaned slowly.

There is still a stigma with these medicines, and our focus is always on appropriateness. All the new red tape means staff at the facilities spend a lot more time collecting data.

Initially it was overwhelming and confusing. GPs were concerned about the impact on their patients. There was also a lack of communication and understanding. The staff are more confident now, but there is still confusion as to what constitutes a chemical restraint.

Now everyone in the care team, including the staff in the home, the GP and the family, are involved in the process. Staff members encourage GPs to look at the psychotropic medicines regularly (at least every 3 months), and the staff assess the effectiveness or otherwise of the medications and consider any adverse effects and update the Behaviour Support Plan. This is considered best practice.

And one of the roles of the credentialed pharmacist is to support the home in filling out the register.

One impact has been a shift to more person-centred care.

The patient is seen as an active participant in their care, which lines up with the new Aged Care Act coming into effect in November this year. The concept is good, but we are still trying to work out how that will work in the long term.

Reviewing the psychotropic register allows us to support our facilities in ensuring appropriate treatments are prescribed and reviewed regularly for the residents.

We can use the register as part of our reviews and for follow-ups.

Nursing staff are more aware of the role of medicines in treating responsive behaviours, and having the register supports their conversations with the GPs. Our role is to be the continuity-of-care person and why we allocate pharmacists to specific aged care facilities, which allows them to become part of the team and provide appropriate advice and support.

We are the second set of eyes. We put a clinical lens over what has gone on and can help the nursing staff. 

Pharmacists are the guardians of medicines management and the advocates for the nursing staff and residents. We help support the residents’ care. 

References

1. Royal Commission into Aged Care Quality and Safety. Final Report. 2021. At: www.royalcommission.gov.au/aged-care/final-report
2. Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. Final Report. 2023. At: https://disability.royalcommission.gov.au/publications/final-report