Sections

Services

Information

UK United Kingdom

Chemical restraint in aged-care homes linked to early death

Last night ABC’s Lateline discussed the case of 63-year-old John Burns, who died within 12 days of going into residential aged care. Burns was put into care after he started to display disinhibited sexual…

Up to 60% of nursing home residents are on psychiatric drugs and around 30% are on powerful anti-psychotics. Ulrich Joho

Last night ABC’s Lateline discussed the case of 63-year-old John Burns, who died within 12 days of going into residential aged care. Burns was put into care after he started to display disinhibited sexual behaviour, and was prescribed anti-psychotics soon after.

The show reported that up to 60% of nursing home residents are on psychiatric drugs with as many as 30% on powerful anti-psychotics. It yet again draws attention to a problem that’s been recognised for over 20 years: the overuse of sedative medication in nursing homes.

And despite strong evidence that many of these drugs are not only often ineffective but may also cause substantial harm (in the worst case, strokes, pneumonia and death), their use appears to be increasing in Australia.

A case study

Lilian moved into the aged care home several weeks ago. She is 84 years old, recently widowed and, two years ago, she was diagnosed with Alzheimer’s disease. Lilian displays certain behaviours that are annoying other residents and some of the nursing staff. The main issue is that she goes into neighbouring rooms and sorts through cupboards, taking out other resident’s toiletries and underwear.

This is a real case that was described to me by nurses who were interviewed for a study looking at sedative medication use in aged care. To address Lilian’s behaviour, a nurse contacted her doctor to discuss the issue and they decided to give her a small dose of diazepam to see if it would help.

Diazepam, better known by its trade name of Valium®, is a long-acting benzodiazepine prescribed mainly for anxiety. There’s limited evidence that it’s effective for managing behaviours associated with dementia. So was it appropriate to prescribe this medication to manage Lilian’s behaviour, or is she being chemically restrained?

Chemical restraint

Medications such as anti-psychotics are often inappropriately prescribed to manage behavioural symptoms of dementia. Ashley Rose

A variety of medications are prescribed in aged-care homes for their sedative properties. Some are used to manage the behavioural symptoms of dementia, and include anti-psychotics and benzodiazepines. And the use of these agents appears to be increasing. A recent study conducted in 44 Sydney aged-care homes found that over 28% of residents were taking anti-psychotic medications. The researchers noted that six years earlier, drug use in the same group was 24%.

So what exactly does the term “chemical restraint” mean? The definition used by the Federal Government is the “intentional use of medication to control a resident’s behaviour when no medically identified condition is being treated, where the treatment is not necessary for the condition or amounts to over-treatment of the condition.”

It may seem obvious to readers that, according to this definition, Lilian is being chemically restrained but many health practitioners working at aged-care homes wouldn’t agree. One director of nursing I interviewed said, “We don’t chemically restrain our residents….anyone that is prescribed a sedative medication has a medical condition; be it dementia, anxiety or a problem getting to sleep.”

Others feel that someone is only chemically restrained when the sedative dose is too high. This broad interpretation of what chemical restraint constitutes, or rather, does not constitute, validates the use of sedative medications for a substantial proportion of aged-care residents.

A growing problem

The prevalence of mental health conditions in the residential aged-care is increasing as the population ages and long-term psychiatric beds remain closed.

According to the latest Australian Institute of Health and Welfare (AIHW) report on aged care, over half of aged-care home residents have dementia. The majority of these residents will have symptoms such as aggressive behaviour, calling out and wandering. Over a third will have anxiety disorders and over half will have disturbed sleep. These statistics indicate that the majority of residents are likely to display mental health symptoms.

Among residents with serious mental illness, such as schizophrenia, major depression and severe aggression, the benefits of using sedatives outweigh harms. But for less serious mental health conditions, using such medication is not ideal.

Giving sedatives to older residents can result in significant harm, including confusion, falls, increased rates of pneumonia and even death, especially in the case of antipsychotics.

For less serious mental health conditions, using sedatives is not ideal. Pedro Ribeiro Simoes/Flickr

Many of these medications only have modest effectiveness in treating difficult behaviours, anxiety and sleep disturbance. And there’s a mounting body of evidence that non-drug strategies can be effective for treating these symptoms. At the very least, non-drug measures should be trialled before sedative medication is prescribed.

Better alternatives

Behavioural symptoms of dementia, anxiety and sleep problems are not always caused by the dementia itself, but can be caused by other underlying medical conditions, such as infections or pain. So it’s important to rule out such causes first before starting treatment. But according to nursing staff, there’s often inadequate assessment of residents.

Non-drug strategies that are effective in managing symptoms include relaxation therapy, personalised music, video tapes of family members, one-on-one time and providing basic counselling and sleep hygiene measures. But many aged-care homes don’t have the staff, training or resources to provide these strategies. As one relative told me, “I just wished that the staff had the time to just be with her and calm her, talk with her and settle her down.”

Excessive sedative use in aged-care homes is thought by many to be symptomatic of problems in funding adequate staffing, training and medical services in this sector. Little progress in reducing reliance on sedative use or chemical restraint can be made until this under-resourcing is addressed.

Join the conversation

41 Comments sorted by

  1. ben walter

    Resident

    It's true that "chemical restraint" is being practised not only in nursing homes but also in most if not all hospital wards across the country as we speak. The reality is that the Australian health care system, and the Australian public have allowed this major health issue creep up on us without even a whimper on the public radar. We as a society are death adverse. In your article you state "even death" as if it were the most unholy and disgusting thing to ever befall a human. It's not. Everyone…

    Read more
    1. Jan Burgess

      Retired

      In reply to ben walter

      I read the whole of this article thinking exactly what you have just said, only not as well articulated.

      The phrase "being kept alive by a medical system that views death as a horrid failing" is the key here.

      It seems to me that until we allow people, particularly older people, the option of euthanasia, we have no alternatives to the current system of out of home care and subsequent need for sedation.

      My husband and I are determined that this will not happen to us and we have made arrangements to be able to exit gracefully before it gets too bad. Many of our friends have similar arrangements. The scary thing is that something may happen suddenly (like a car accident or a stroke) that leaves one at the mercy of the medical profession.

      report
    2. Sue Ieraci

      Public hospital clinician

      In reply to Jan Burgess

      Jan - you say ""being kept alive by a medical system that views death as a horrid failing" is the key here." - but it's not that simple.

      Much futile medical care in the very elderly occurs because of either the insistence, or lack of planning, amongst family members.

      The best way to avoid futile medical care in the hands of the hospital system is to avoid going there. Once a person is taken to hospital (generally an emergency department, where they may not be known) pathways are set in motion…

      Read more
  2. John Q Citizen, Aussie

    Administrator

    One 'facilty' our parent recently went to had a nurse patient ratio of 1 Nurse to 50 patients! The RN on the medications trolley was frequently 2 hours behind. Time release meds such as Seroquel, prescribed by the appropriate Physician resulted in many patients presenting with extreme symptoms.

    Funding to these facilities has to be more closely monitored. Some appear to be little more than 'Club Med for the Aged" The Clt Dept for Health & Aged needs some teeth or maybe just more of them. Each pateint appears to be a revenue stream and why do a lot ot 'facility owners' drive nice big 4WD's?

    report
  3. Daniel Haszard

    logged in via Facebook

    Thanks for posting this vital information.The Eli Lilly company made an astounding $65 BILLION on Zyprexa that they PUSHED on the elderly and underage children (*Viva Zyprexa* Lilly sales rep slogan) with wanton disregard for the side effects
    *FIVE at FIVE*
    The Zyprexa antipsychotic drug,whose side effects can include weight gain and diabetes, was sold to Veterans,children in foster care, elderly in nursing homes.
    *Five at Five* was the Zyprexa sales rep slogan, meaning *5mg dispensed at 5pm would keep patients quiet*.

    *Tell the truth don't be afraid*-- Daniel Haszard FMI http://www.zyprexa-victims.com

    report
  4. Bruce Moon

    Bystander!

    Juanita

    I'm very much 'with you' on this topic.

    My wife and I have personally been involved with family members going into care - and coming out of care (at our discretion).

    We support the use of care as a means to address problems when the independent living option is exhausted. But, from our experience it is an extremely 'last resort' option for the reasons you describe.

    To explain (using one case), recuperating from a fall and hip replacement for an independently living aged single…

    Read more
  5. john mills

    artist

    http://psychroachesadverseevent.blogspot.com.au/2009/03/zyprexa-adverse-reactions.html If that link, doesn't make you wonder why the elderly go down hill, so rapidly, when they hit the nursing home, nothing will. Cameras in every room, staying alive is more important than privacy, the same goes for all mental health facilities, who are killing one person a day nationally in their care, and don't even have to be accountable to anyone but themselves, in fact the government says so. I could write for ten pages on the abuses by psychiatry and mental health, and id only be getting warmed up, babies, youth, and elderly, all (70%),each, a subject of mental health discourse, abuse, in themselves, so thats enough for today, catch.

    report
  6. Sue Ieraci

    Public hospital clinician

    This is such an important and difficult issue - and set to become more pressing as the population of the old-old expands and dementia is more common.

    The author is correct that sometimes sedation may be the only solution when there is not enough availability of skilled staff. But this isn't simple to solve, and is not the only problem.

    Dementia-specific nursing homes have a dual challenge: patients who are difficult to manage, living in a group setting. Many dementia patients have reversed…

    Read more
  7. Chris Weir

    Analyst

    This is a broad issue but to concentrate on one area if I may how do GP's, Hospitals et al get away with prescribing drugs like Seroquel and Risperdal outside of the requirements of the TGA & PBS?

    Approvals for the use of these were specific when approved as a medicine for example short term use for schizophrenia and bi-polar disorders.
    The conditions if prescribed through the PBS thus obtaining a subsidy are also covered by prescribing conditions.
    A streamlined authority is required to issue…

    Read more
    1. Sue Ieraci

      Public hospital clinician

      In reply to Chris Weir

      Chris Weir - many useful drugs are used "off label." All that means is that new indications for those drugs have appeared, but the pharmaceutical companies don't bother getting approval for those indications because it is not worth their investment.

      Ultimately, the prescriber is responsible for their actions and outcomes.

      Anti-psychotics and other sedatives are often needed for acute illness in the elderly to control behaviour that is dangerous to either the person for their fellow patients. This is not "punitive" control - it is to stop the person pulling out their IV drips, pulling off dressings on wounds, trying to climb out of bed, shouting all night while others are trying to sleep - these symptoms of "delirium" are common in the elderly with infections, for example.

      Managing a whole ward of sick elderly involves compromises, for the care of all. One-to one nursing would be great - but how is it feasible?

      report
    2. Chris Weir

      Analyst

      In reply to Sue Ieraci

      Yes, Sue. In the circumstance you refer to it's understandable that some form of sedative would be required.
      But, and its a big but, anti psychotics should not be used to make life easier for the night staff: we are talking about human beings here.
      If they don't have the conditions these are approved for the elderly should simply not be given them.
      In my view in an aged care setting we are entitled to expect that those who have the responsibility must not just care for them but about them.
      Often this is found sadly lacking from my personal family experiences notably in the 'for profit' people farms

      The FDA has the drugs mentioned carry the severest warnings, in turn the Big Pharma companies have had to pay $millions in settlements both in the US and Europe.
      Although 'counseling' is one thing offered to the prescribers, if they get found out of course, stand by for a class action I would suggest.

      report
    3. Chris Weir

      Analyst

      In reply to Sue Ieraci

      Addendum; Sorry Sue, I meant to mention a couple of things about your response above.

      You say that new indications may have appeared.
      How does one get to know what these indications are as they are certainly not on the information available from the TGA for the two items I mentioned.
      How is the veracity of claims of a new use checked?

      And in respect of prescribing via the PBS for something outside of the prescribing conditions they have determined (the approved indications and term of treatment) is it right in your view that the PBS subsidy should be available?

      report
    4. Sue Ieraci

      Public hospital clinician

      In reply to Chris Weir

      Chris - there is no "compendium" of drugs that have found uses beyond their original ones - the knowledge is in the medical literature and in accepted clinical practice.

      Some examples of medications with multiple uses:
      Beta blockers - developed for high blood pressure, found to be good for congestive heart failure
      Carbamazepine (Tegretol) - older anti-convulsant - good for controlling the pain of neuralgia
      Even the simple pain-killer aspirin has both anti-inflammatory and anti-platelet ("thinning the blood") properties.

      There are many, many other examples - well-established, so, yes, of course these should be subsidised on PBS.

      Prescribers are held accountable for their practice. IF you cannot be satisfied with an explanation from the prescriber, perhaps ask for some supportive evidence, or ask for another opinion.

      report
    5. Sue Ieraci

      Public hospital clinician

      In reply to Chris Weir

      Chris - you need to recognise the reality of a group care setting - it is not just about making life easier for the staff (though that is a reasonable aim, I would argue) - it';s also to help control the environment for other residents, as well as to help prevent the people harming themselves.

      Nursing homes are environments stifled with compromise - financially, socially (group-living without choice of neighbours), organisationally. IN general, people live there because they either have no-one to care for them, or their families are unable to provide the intensive round-the-clock care that these people need. Many spouses have been brought almost to the point of breakdown themselves in trying to provide this care.

      This is not a "class action" situation. There is lots written in the Aged Care and Palliative Care literature on the judicious use of anti-psychotics in the elderly - especially when an acute infection of lack of oxygen causes a temporary delirium state.

      report
    6. Juanita Westbury

      Lecturer in Pharmacy Practice and Research Fellow at University of Tasmania

      In reply to Chris Weir

      Hi Chris,

      As part of my PhD I performed several audits of 40 aged care facilities throughout Tasmania over a period of several years. Many residents (6% in fact) were taking olanzapine (zyprexa) for behavioural symptoms associated with dementia. Like you, I was puzzled how they were able to attain these medications so easily. They cost the PBS over $200 a month yet all of the olanzapine was subsidised by the PBS (i.e. most residents only pay $5.80). To get these medications the GP has to declare…

      Read more
    7. Juanita Westbury

      Lecturer in Pharmacy Practice and Research Fellow at University of Tasmania

      In reply to Sue Ieraci

      Hi Sue,

      Yes, you are right when you say the use of antipsychotics is justified in some cases. But it should be noted that over 28% of residents were taking antipsychotics in a sample of 45 nursing homes in central Sydney several years ago. I very much doubt that this percentage of residents were psychotically aggressive or required end-stage palliation. Research has shown that these drugs are mostly used to control shouting, calling out, agitation, wandering and apathy - indications that there…

      Read more
    8. Sue Ieraci

      Public hospital clinician

      In reply to Juanita Westbury

      Juanita - I'm sure you're right that ideal prescribing practice doesn't always happen in nursing homes. As I said above, residential aged care is generally a compromise of cost, social and physical circumstances and group living.

      It would be ideal to have pharmacists review medications for NH residents on a regular basis - does this ever happen? Could pharmacy students volunteer to do it?

      report
    9. Chris Weir

      Analyst

      In reply to Sue Ieraci

      Sue; The three items you have chosen show the following on the PBS info.

      Beta Blockers- mostly require a streamlined authority, a randomly chosen check shows congestive heart failure as an indication.

      Carbamazepine- shows neuralgia as an indication.

      Aspirin- Listed as having both analgesic and anti-thrombotic indications.

      Thats the difference.

      For these other drugs 'accepted clinical practice' by whom?

      A study here in Melbourne suggested that in some cases the prescribing of these drugs was more a habit than a solution.

      report
    10. Chris Weir

      Analyst

      In reply to Sue Ieraci

      The NPS is and has been involved in education regarding the inappropriate use
      of these drugs and sedatives per se.

      report
    11. Sue Ieraci

      Public hospital clinician

      In reply to Chris Weir

      "For these other drugs 'accepted clinical practice' by whom?"

      "Accepted clinical practice" means amongst practitioners who work in that area. You will find lots about delirium and sedation in the Aged Care/ Geriatrics literature, including the newer anti-psychotics (which happen to be much better than the older ones, which had lots more side-effects and long-term effects).

      Here is a good Australian paper on off-label use of drugs, written by a group of pharmacists:
      https://www.mja.com.au/journal/2006/185/10/label-use-medicines-consensus-recommendations-evaluating-appropriateness

      report
    12. Chris Weir

      Analyst

      In reply to Sue Ieraci

      And here's a 2012 message from the NPS
      http://www.nps.org.au/consumers/publications/medicines_talk/medicinestalk_no.39_january_2012/off_label

      Also in the BMJ not so long ago there was a group expressing some disquiet about 'accepted clinical practice' in the context of who was claiming some drugs to be OK when they could be perceived to have a close association with the manufacturer.
      If the explanation is ' we have heard' or 'we think' is supposed to be good clinical practice it wont do.
      And both Seroquel and Risperdal are of the newer group are they not?

      As a footnote; I am fully aware what off-label means; I take one such med myself.

      report
    13. Sue Ieraci

      Public hospital clinician

      In reply to Chris Weir

      Chris - if you are aware of off-label use, why are you alleging conspiracy and class actions?

      If you already take a medication on off-label use, how did you determine whether or not it was best -practice?

      Perhaps you don't realise how much ongoing discussion and development occurs in the medical literature, conferences, workshops, education sessions, in the workplace.

      report
    14. Chris Weir

      Analyst

      In reply to Sue Ieraci

      One thing I do realise is that the ego's of some the participants seem to override what the National Health Act and amendments set down as law in this country.
      As you will note if you read the link from the NPS certain things are meant to apply.
      As I said earlier it goes back to the veracity of the information and it is the Drug companies that are meant to apply for extra and new indications not a consensus by a bunch of people at a conference for example.
      I would be so bold as to suggest that…

      Read more
    15. Rhonda Nay

      Emeritus Professor La Trobe University at La Trobe University

      In reply to Sue Ieraci

      Sue - inappropriate drug prescribing and administration does not only happen in resi care - the number of REPORTED drug relate adverse events in hospitals is frightening. In fact I would argue that older people probably get better care in nursing homes (even with fewer staff) than in hospitals where they are considered bed blockers. I would be very interested Juanita to see a follow up of your work charting how many people with dementia have 'unexpected deaths' in hospitals vs nursing homes.

      report
    16. Sue Ieraci

      Public hospital clinician

      In reply to Chris Weir

      Chris - I suggest you think about what Robert wrote above:

      "Fooling about with trying to achieve perfection in medication rather than making a person happy and more comfortable for that last years of their life, keeping in mind a drug addiction is no problem if you have ready access to the drug."

      I am involved in the care of many old people at the end of life - many who are very disabled and have severe dementia. I also have personal experience with family members in this setting. I love working…

      Read more
    17. Chris Weir

      Analyst

      In reply to Sue Ieraci

      Sue- I don't doubt your dedication to your position.
      This is not about such matters.
      In the first place as the author of this article points out 'Among residents with serious mental illness, such as schizophrenia, major depression and severe aggression, the benefits of using sedatives outweigh harms. But for less serious mental health conditions, using such medication is not ideal.
      Giving sedatives to older residents can result in significant harm, including confusion, falls, increased rates of…

      Read more
  8. Kenneth Mazzarol
    Kenneth Mazzarol is a Friend of The Conversation.

    Retired Auto Engineer and teacher

    If innocent elderly can be administered drugs to make them easier to handle. why is there an argument against giving criminal recidivists mind altering drugs to quieten them down and giving them back to carers, rather than sentencing them to over-crowded prisons where, as well as costing us millions to house, they continue to be a problem???

    report
    1. Sue Ieraci

      Public hospital clinician

      In reply to Kenneth Mazzarol

      Mr Mazzarol - antipsychotic medications help control psychotic symptoms and agitation. They don't make people make better moral choices.

      report
    2. john mills

      artist

      In reply to Kenneth Mazzarol

      No argument at all Kenny, and whilst were at it lets drug all the troublemakers, and the thief's, all the loud and aggressive people,all the fare evaders,all the disobedient little people,all the wayward teenagers, all illegal drug takers, all the alcoholics,all the old people, i mean everyone's got a problem these days,maybe we should drug the planet, bring on 1984, ye ha!!!, a pill for you and a pill for me. get us all acting within the psychiatric guidelines(control) of what constitutes, "acceptable behavior".

      report
  9. Robert Tony Brklje
    Robert Tony Brklje is a Friend of The Conversation.

    retired

    Over medication versus incorrect medication. Growing older means loss of physical ability and increasing levels pain and discomfort.
    How do we as a society differentiate so called 'artificial' happiness for 'true' happiness. If happiness can be provided in a pill should it be denied because it wasn't bought and paid for through consumerism.
    Restrained by medication or set free by medication. Feeding pharmaceutical patents or using simpler more readily and cheaply accessible drugs, that a frowned upon because they are addictive.
    Fooling about with trying to achieve perfection in medication rather than making a person happy and more comfortable for that last years of their life, keeping in mind a drug addiction is no problem if you have ready access to the drug.

    report
  10. Rhonda Nay

    Emeritus Professor La Trobe University at La Trobe University

    My comments relate to the conversation as a whole - not just this article. I am told there are situations where doctors believe that a diagnosis of dementia is sufficient reason to hasten death - or in my view engage in involuntary euthanasia. We really need to decide as a society if increasing life expectancy is a success - which we normally assume it is. If the result - an ageing population - is then such a crisis rather than debate killing them off when their behaviour becomes inconvenient perhaps…

    Read more
    1. Chris Weir

      Analyst

      In reply to Rhonda Nay

      Thanks for your comment as it hits the nail right on the head for me.

      Comments also on the broader subject.

      You mentioned advance care plans.
      With the eHealth system, although not that many have yet registered for it, when carrying out the process of adding what data is possible there is an area where one can nominate a Custodian or organisation that can hold a written document, an Advance Care Directive outlining personal wishes for future health and care.
      There is a system 'Respecting Patient Choices' that I believe operated at the Austin but may be more widespread now.

      And on diagnosing dementia I have been quite amazed that some Drs and staff are able to do this seemingly from the bedroom door rather than follow guidelines like those of the NHMRC which require slightly more complex attention.

      report
    2. Rhonda Nay

      Emeritus Professor La Trobe University at La Trobe University

      In reply to Chris Weir

      Yes Chris I have had some involvement with RPC. Unfortunately the international literature indicates that hospital staff do not see/ follow the stated wishes on many occasions. More work needs to be done on the processes and structures to ensure the wishes can not be missed - I did hear of a great idea of having NFR tatt on your front and PTO on your back.
      Now that dementia has been made a national priority the great work already undertaken - especially by Alzheimer's - will hopefully get some more support. We have some really good Guidelines but getting them into practice is the opportunity!!

      report
    3. Sue Ieraci

      Public hospital clinician

      In reply to Rhonda Nay

      Rhonda - my experience with the very disabled very-old makes me disagree with you here: I do not believe that the pursuit of longer life is ethical in all situations.

      I see no evidence of the elderly being "killed off" just because they have dementia. I see something more distressing - very old people with advanced dementia being kept alive by acute intervention when their entire body is failing.

      As you will now, one of hte common reasons for this group of patients (very disabled very old…

      Read more
    4. Rhonda Nay

      Emeritus Professor La Trobe University at La Trobe University

      In reply to Sue Ieraci

      Nor do I - indeed I am very much in favour of ACP to stop heroics when they are not wanted or sensible. I have already written my ACP to stop precisely that. But this is different, as is good pain management, to hastening death because someone with dementia is agitated, annoying others and so on. There are interventions that are appropriate in these situations and that improve life for the person with dementia, their families and staff. Sedatives, antidepressants, antipsychotics and morphine all…

      Read more
    5. Chris Weir

      Analyst

      In reply to Sue Ieraci

      Just to pick up on this; When it comes to ethics who decides?
      You will be aware I should think of the program in the UK, The Liverpool Care Pathway, which has attracted a lot of criticism and has been described by some very qualified medical people as an assisted death pathway, forget the care. As recently as June this year Prof Pullicino said this; ' "Very likely many elderly patients who could live substantially longer are being killed by the LCP. Patients are frequently put on the pathway without…

      Read more
  11. Chris Weir

    Analyst

    A follow up from the original Lateline item last night,

    http://www.abc.net.au/lateline/content/2012/s3579035.htm

    Wheels move very slowly but how many Health Ministers have had the problem bought to their attention from research within Australia and from the general 'small minnow' public.
    What does it take to get action.

    report
  12. Sophie Stephens

    penresidentialcare at Aged Care

    The post is very nicely written and it contains many useful facts. I am happy to find your distinguished way of writing the post. Now you make it easy for me to understand and implement. Thanks for sharing with us. <a href="http://www.penresidentialcare.com.au">Supported Residential Services - South East Melbourne</a>

    report