Chemical restraint in aged care
New rules designed to “minimise” the practice of physically restraining or doping elderly residents in nursing homes are so poorly written they will backfire and lead to a rise in the use of chemical control, experts have warned.
The federal government’s own aged-care watchdog, the Aged Care Quality and Safety Commission (ACQSC), raised concerns during a blink-and-you’d-miss-it consultation period for the new principles, asking whether they would actually see overprescribing “legitimised”.
Despite arguing the regulation of restraints is an “area of significant risk”, the commission’s concerns were ignored, and key clauses went to the senate to be passed without any changes.
The consequences of such expediency may be severe.
Physical restraint of elderly residents can prompt a visceral reaction from those who witness the practice. Some nursing homes even instruct staff to ensure visitors can’t see residents who are being restrained.
The widespread practice of sedating or doping residents, meanwhile, has largely managed to avoid controversy despite being deadlier and, when understood, several orders of magnitude more horrifying for the resident involved.
In a scathing report on chemical restraint released on Wednesday, Human Rights Watch called for new government regulations to be replaced with rules that penalise instead of normalise these practices in nursing homes.
The report’s authors, led by Bethany Brown, HRW’s researcher on older people’s rights, cited a study that showed anti-psychotics being prescribed to more than one in five nursing home residents, with sedatives prescribed to 43 per cent. The actual rates of overprescribing may be even higher.
Susan Ryan spoke to the researchers about the loss of dignity of her father, 78-year-old Ray. “He was very, very depressed, just crying all the time,” she said. “And he couldn’t swallow... He would say, ‘My mind is a hell to me.’ He wouldn’t be engaged in a conversation… All his symptoms are side effects of the anti-psychotics, and they disappeared after he went off [them].”
Many of the drugs used to chemically restrain those in aged care were never developed for elderly people and carry explicit warnings about side effects. Risperidone, for example, was designed specifically for the heavy psychosis that can accompany schizophrenia. It is banned for dementia patients in the United States, but in Australia the Therapeutic Goods Administration has approved the anti-psychotic drug for up to 12 weeks’ use.
Diazepam, commonly known as Valium, is also prescribed as a sedative. It is the strongest benzodiazepine on the market and gerontologists have warned it should never be given to elderly patients. To sedate elderly patients, antidepressants and anti-anxiety medications are also prescribed off-label. The most powerful of these is mirtazapine. In older people, as kidney and liver function declines, the already powerful effects of these drugs become more pronounced.
“Pharmacists, lawyers, and policy experts have criticised the [government] regulations for failing to prohibit chemical restraint, perpetuating the use of restraints to control people’s behaviour, and failing to include a requirement for informed consent and provisions to allow for refusal,” the HRW report says.
“The rules also do not include any specifications about complaints and recourse – there is no penalty or sanctions specified for facilities or staff that inappropriately administer medication. The regulation does not specify which entity is tasked with monitoring it.”
In most cases, residents start on a cocktail of drugs or have existing doses increased significantly the moment they enter a home, ostensibly to manage “difficult behaviours” but often, according to testimony from expert groups at the Royal Commission into Aged Care Quality and Safety and other inquiries, due to “institutional convenience”.
But the side effects can go beyond cognitive decline and become fatal.
Take the case of 83-year-old Margaret Elizabeth Barton, who entered residential aged care in Victoria in early 2015, first as a respite resident at a CraigCare Mornington home and then permanently at Mecwacare Park Hill. The day after her admission, Barton was placed on a daily dose of 15 milligrams of the sedative oxazepam to control her agitation. Her behaviour ranged from being “verbally and physically intrusive … [to] repeatedly stating she wants her husband and to go home”.
This is a common response for those who enter care for the first time, due to the confusion, distress and anxiety of their new surroundings.
A few weeks later, Barton’s dose of the sedative was tripled to 45 milligrams a day. On February 17, she fell for the first time, shortly after receiving her second oxazepam dose for the day. From her first admission, Barton fell a total of 10 times while in care at CraigCare Mornington and Mecwacare Park Hill, before her death on March 29, 2015.
“The evidence satisfies me that there is sufficient correlation between Mrs Barton’s multiple falls and the oxazepam, to conclude that the medication regime contributed to her physical decline and death,” acting state coroner Iain West wrote in his findings, published in February this year.
West went further, linking the “excessive” doses to Barton’s pneumonia – another side effect of the drug – and the exacerbation of behaviours associated with dementia, the very thing for which the sedative was administered.
In one 19-hour period while at Mecwacare Park Hill, Barton was given 90 milligrams of oxazepam.
It was a vicious circle. Due to her falls, Barton suffered a series of fractures to her ribs, pelvis and vertebrae, many of which went unnoticed. “The fractures did likely contribute to Mrs Barton’s agitation and distress, and may have led to unnecessary oxazepam use,” the coroner said.
Assistant secretary of the Victorian branch of the Australian Nursing and Midwifery Federation Paul Gilbert told the aged-care royal commission on Wednesday that there is “not enough staff, simple as that”.
He said: “The registered nurse staff … have professional obligations. They can only delegate care to people who they have assessed as being competent, and they don’t have … the staff numbers, or the level of skill required for that safe competent delegation to occur.”
Restraint is often a substitute for staff and HRW has also recommended “a 24/7 registered nurse presence in all aged-care facilities and … stronger minimum staffing levels and ratios or other enforceable minimum requirements to ensure continuous, person-centred support for older people in aged care”.
An audit in February 2019 by the ACQSC into one nursing home, Greenway Gardens, was provided to the aged-care royal commission this week. It shows that 47 per cent of all residents were at “increased risk of falls or confusion” due to medication that blocked a certain neurotransmitter in the brain.
A cache of emails tendered as an exhibit to the royal commission reveals the Department of Health attempted to divert or delay efforts to properly regulate restraint in aged care, despite demands from then Aged Care minister Ken Wyatt.
On February 13, a public servant wrote: “I do not think we need to include clinical experts as we are not developing a clinical resource – it is purely administrative.”
This was shot down by another bureaucrat and a consultation with the government’s clinical advisory committee was ordered. An aged-care clinical advisory committee was formed and its members picked up on similar concerns to the sector watchdog, the ACQSC, about the definition of chemical restraint.
In March, Professor Henry Brodaty, a psychiatrist, wrote in the margins of an options paper about the definition: “This is very grey area, and open to interpretation e.g. is anxiety (which overlaps with aggression) a mental disorder?”
In the same document, another member – Dr Richard Kidd, a GP – warned about the breakdown in workforce numbers in aged care. “This is a fundamental structural safety and quality issue underpinning clinical governance [and] effective behavioural management,” he wrote in the margins.
University of Tasmania researcher Juanita Breen is the author of the largest study conducted into the prevalence of sedation in nursing homes and how it might be controlled. Funded by the former Labor government to the tune of $4.1 million, her project – known as Reducing Use of Sedatives, or RedUSe – studied more than 12,000 aged-care residents in 150 facilities.
“We achieved a 21 per cent decrease in benzodiazepine use across 150 homes – and a 13 per cent decrease in anti-psychotic use,” Dr Breen tells The Saturday Paper. “Behaviours [associated with dementia] did not increase. Quality of life improved a little. As a conservative estimate, if extended, we estimated cost savings in excess of program delivery costs could be achieved in medication cost savings alone. That does not factor in reduced hospitalisations from falls, pneumonia or GP consultations.”
Inexplicably, the program was not extended and its funding never renewed.
Nevertheless, RedUSe was continually cited as an excellent resource by the government’s clinical advisory group, and the Department of Health provided it as evidence to Human Rights Watch that the government had invested in programs “aimed at reducing the use of sedative and anti-psychotic medications in residential aged-care facilities”.
Dr Breen says the results were transformative. “Some residents woke up. One spoke for the first time in a year.
“Perhaps they [the government] thought that these … projects would ‘fix’ the problem and don’t realise that other homes, [the] 95 per cent of all the other Australian aged-care homes that did not take part, would have to actually do the program to get any benefit.”
Now the Commonwealth has no such program in place and a set of new “rules” that look likely to push the use of restraint into acceptable regulation.
In a submission to the parliamentary inquiry on the new rules, Queensland’s Office of the Public Guardian said they “represent a significant worsening in rights protection for these adults”.
“If the new Principles remain in place unamended, the OPG predicts there will be a rise in the use of chemical restraint upon aged-care residents,” the submission says. “This is foreseeable because a weaker threshold has been applied in relation to consent – and it is likely that in a resource-constrained environment, with staff who are ‘stretched’ – they will opt for the restraint which would appear to be ‘less work’ for them. This is extraordinarily dangerous.”
Dr Breen told The Saturday Paper the rules have ended up “appeasing prescribers and aged-care homes”.
The ACQSC did not respond to specific questions about its concerns that the definition of chemical restraint could legitimise overprescribing, with providers using a patient’s physical or mental condition to justify the drugs.
Dr Breen says this is a crucial loophole. “If you look at the AIHW [Australian Institute of Health and Welfare] data, 86 per cent of all aged-care residents are classified as having a mental illness or behavioural condition,” she says.
“You could even include dementia as a physical condition, which destroys the whole point of these rules. That’s what dementia is, it’s the breakdown of physical structures in the brain.”
The aged-care royal commission will deliver its interim report to the governor-general on October 31, following the shock death of chief commissioner Richard Tracey last week, just seven weeks after his cancer diagnosis. Tracey had already co-authored the report with the other commissioners before his death, so there will be no delay.
Tony Pagone, QC, was appointed as the third royal commissioner last month and will now oversee the inquiry, which has been granted a six-month extension. The final report is due on November 12, 2020.
This article was first published in the print edition of The Saturday Paper on Oct 19, 2019 as "Sedating sites". Subscribe here.