Restraints in aged care a last resort: RACGP President

Matt Woodley

20/08/2019 4:40:09 PM

Dr Harry Nespolon advised a Parliamentary Committee to not use ‘prescriptive’ legislation to limit restraints in RACFs.

Older man in wheelchair
The committee is investigating legislation regulating the use of restraints in aged care.

Dr Nespolon made the comments at a public hearing investigating the Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019, and stressed that any regulation needs to reflect ‘the reality’ of what happens in residential aged care facilities (RACFs).
‘I spoke to a whole lot of our members who work in aged care facilities around Australia, and the message they said to me is that they use [chemical restraint] last,’ he said.
‘You’ve got to get some perspective. When you’re sitting in a room like this and all you’re talking about is chemical restraints, you have this vision of all these [RACFs] with 90% of the patients with some sort of restraint. That’s not what happens.
‘Less regulation is better than more. There’s no perfect system and that’s why we have standards and accreditation … [but] most people are trying to do the best in the circumstances that they are in, given the resources that they have.’
Speaking after the hearing, Dr Nespolon told newsGP he is also against a push to include a mandatory requirement for geriatricians to be involved when prescribing psychotropic medication.
‘We don’t agree that there has to be a geriatrician involved in making decisions about patients,’ he said. ‘GPs can make up their minds … as to whether or not they need to call in any additional assistance, just like any other day, like any other patient.’
During the hearing, geriatric medicine specialist Professor Susan Kurrle described GPs as the ‘linchpin’ of medical care for older Australians, but argued only ‘specialists’ should be allowed to prescribe psychotropic medications.
‘We have the Dementia Behaviour Management Advisory Service [DBMAS], Commonwealth-funded and available across Australia. They should have to see residents before [physical] restraints are prescribed,’ she said.
‘GPs are being lent on [by RACFs] to prescribe something, or to say the person can be tied up because they’re causing difficulties. That will often be where they will call a geriatrician … to get involved, [and] that’s when I think they should be talking to DBMAS.
‘I say that having discussed that with a lot of my general practice colleagues who all say, “That would be fantastic. It would save us being hassled by family and by residential care staff”.’
During the hearing, Senator Nick McKim also questioned whether the different wording surrounding the appropriate use of chemical and physical restraints means there are different thresholds as to when either can be applied.
Professor Kurrle said there needs to be consistency between the circumstances that require the use of chemical and physical restraints, and said any legislation should make the use of restraints more difficult than ‘good clinical practice’.
However, there was also debate over what use of psychotropic medication constitutes chemical restraint, as opposed to the prescription of medication for therapeutic purposes.
Dr Roderick McKay from the Royal Australian and New Zealand College of Psychiatrists told the hearing he had seen patients have negative experiences, after being taken off psychotropic medication primarily due to fears of overprescribing and whether it would be deemed a use of chemical restraints.
‘Both myself and other psychiatrists are having an increased numbers of conversations with GPs, who are very concerned about either commencing or continuing psychotropic medication for any purpose,’ he said.
‘There is a fundamental difficulty, though, with actually defining “chemical restraint”. On the ground, definitely, psychiatrist experience is that actually GPs are probably now not prescribing at times when they should be prescribing because they fear that it will be considered chemical restraint.
‘There’s a great difficulty around the definition, which makes everything else very difficult.’
Dr Nespolon also said he found the distinction difficult.
‘It’s quite an interesting question about whether you can look at a patient and say, “we’re just chemically restraining you”, as against dealing with other mental issues at the same time,’ he said.
‘Trying to imagine a patient that’s just getting their medication just for chemical restraint – I find really difficult.
‘The patients that you see are much more complex and [it’s] much more difficult to just give them a single diagnosis. In fact, I doubt if there’s anyone in a nursing home who has a single diagnosis.’

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Adj Assoc Prof Robert Davis   21/08/2019 8:46:35 AM

We have been dealing with the issue of the use of "chemical restraint" in people with intellectual disability for 2 decades now. The problem is that with a lack of alternative management, medication has been used to deal with challenging behaviours that endanger the person and those around them. There needs to be funding for resources directed at non pharmaceutical management of behaviours supplemented with training of aged care staff and GPs if things are to change.

Catherine Harman   21/08/2019 11:47:28 AM

If geriatricians and nurse practitioners feel they are better qualified to take over the management of RACF patients start assigning them to facilities and let them be responsible for ongoing patient care. An endless amount of paperwork is now being generated for psychotropics including maxolon, antidepressants,Parkinson's meds as well as the antipsychotics. Bring on geriatrician management - I'm more than happy to give it to salaried "specialist" practitioners and they can handle the 24/7 phone calls and become the paperwork slaves for this industry. Are DBMAS going to provide an acute after hours service as well? My only experience with them is that they take weeks to get back and don't actually physically review the patient - yet their input seems more highly valued than GPs. If it is mandated that certain groups are to dictate management then they will need to assume responsibility for long term ongoing care and make themselves readily available to sort out any issues that arise.

Dr Jo   21/08/2019 1:04:40 PM

Could not agree more Dr Catherine Harman.

Nick Bretland   21/08/2019 3:04:08 PM

A major issue is residents who are rarely violent, but when they are, can cause significant injury. If I do not prescribe a prn medication, then the RN on duty will send the resident to hospital. The ambos strap everyone ( regardless of conscious level) onto the stretcher ( physical restraint) . If the resident resists, they call for police assistance. Thus, if I don’t prescribe a prn sedative, the decision on type and dose of restraint may be left to a junior police officer, in order to get the resident to ED.

Dr Juanita Breen (previously Westbury)   21/08/2019 5:10:20 PM

I have been researching psychotropic use in aged care for over a decade and ran a project called RedUSe to reduce inappropriate prescribing. This was published in the MJA last year. I agree that the term 'chemical restraint' is not defined well and I never used it in conversations with the 172 aged care homes that participated in RedUSe. Interestingly, directors and nurses often raised this issue with me, claiming there was absolutely no chemical restraint used in their homes as antipsychotics and other drugs were only used in people with dementia - a medical condition - so all use is justified.
But I think much of the psychotropic prescribing is inappropriate - 22-28% of residents are taking antipsychotics every day - for average periods exceeding a year - without monitoring for effect and side effects are often down played. Use is justified with prescribers and staff saying ' but it's only a small dose'. Prn charting is also widespread. Who decides then whether to use it or not?