Australia's problem with obtaining consent for psychotropic use in older people

Peisah, Carmelle; Jessop, Tiffany

doi:10.1111/imj.15274

Cited by 5 publications

(11 citation statements)

References 7 publications

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“…When a person cannot give their own consent, a legally defined substitute decision-maker, such as the person responsible, attorney, or guardian, needs to provide consent. Informed consent cannot be provided by staff members, allied health professionals, or the provider on behalf of the person [ 49 – 51 ]. Psychotropic medication has a history of use in the treatment of dementia behaviours within residential aged care in Australia [ 13 , 52 ] and in other countries [ 53 – 55 ].…”

Section: Resultsmentioning

confidence: 99%

“…Psychotropic medication has a history of use in the treatment of dementia behaviours within residential aged care in Australia [ 13 , 52 ] and in other countries [ 53 – 55 ]. Some of this history includes the use of antipsychotics, without consent from the family, next of kin, or those holding power of attorney [ 7 , 19 , 51 , 56 ]. Relatives of people living with dementia in Australian residential aged care homes are documented as expressing their frustrations to learn that psychotropics were administered without their knowledge [ 19 ].…”

Section: Resultsmentioning

confidence: 99%

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Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

2023

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Background The prescription of psychotropic medication to older people living with dementia in residential aged care has become an increasing concern. The use of prescription medication is often prefaced as a way of preventing harm to self and others. However, the use of such medications has been considered a way of managing some of the behavioural and psychological symptoms of dementia. Using a large secondary data set, this study aimed to identify the precursors and mediating factors that influence the use of chemical restraint of older people in residential aged care. Methods Publicly available documents from the Australian Royal Commission into Aged Care Quality and Safety were used as the data corpus for this study. Keywords were used to search over 7000 documents to extract a set of topic-related content. We identified the cases of seven people in respite or permanent residential aged care who had been prescribed or administered psychotropic medication under circumstances that appeared to demonstrate chemical restraint. All documents relating to the cases were collated for our data set. A descriptive case study approach to analysis was taken. Results Four key descriptive patterns were identified: labelling and limits to tolerance, pushing prescription as a solution, coverups and avoiding consent, and family’s fight for liberty. Triangulation across the data and academic literature supports the findings. Conclusion Our findings provide some insight into how chemical restrain happens. Featuring throughout the cases were reports of a lack of workforce capacity to care for and support residents exhibiting dementia behaviours. Prescription of psychotropic medications featured as a “first resort” care solution. Family and friends found such approaches to care unacceptable and frequently challenged the practice. Where consent for prescription was explicitly denied, more covert approaches are demonstrated. Family awareness, presence, and advocacy were key to challenging the practice of chemical restraint. Shortfalls in the capacity of the current workforce come into play here. However, workforce shortcomings can no longer mask this ubiquitous practice. Just as importantly the spotlight needs to be turned on the prescribers and the providers.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

2023

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“…These results, together with our examination of antipsychotic persistence among individuals in whom therapy was newly commenced, suggests that most older people with dementia taking an antipsychotic are treated for >90 days. This practice did not align with local recommendations during the study period, 42 nor current guidelines 20 that recommended initial treatment not exceed 12 weeks when antipsychotics are used for managing the behavioral and psychological symptoms of dementia. We also found that prior antipsychotic use was strongly associated with higher incidence of prolonged use in both cohorts, and little geographical and PRAC facility variation was observed.…”

Section: Discussionmentioning

confidence: 96%

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services

Sluggett,

Caughey,

Air

et al. 2024

Int J Geriat Psychiatry

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ObjectivesDementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non‐drug interventions fail, and to regularly review use. Population‐level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC.MethodsRetrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011–12 to 2015–16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function.ResultsBetween 2011–12 and 2015–16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2–11.1) to 10.1% (95% CI 9.6–10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95–0.98)), and in PRAC residents from 24.5% (95% CI 24.2–24.7) to 21.8% (95% CI 21.5–22.0, aIRR 0.97 (95% CI 0.96–0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108–958) and 555 (IQR 197–1239) days, respectively.ConclusionsWhile small decreases in antipsychotic use >90 days were observed between 2011–12 and 2015–16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

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“…Prime amongst these is a failure to respect autonomy, manifested by failure to obtain consent (including substitute consent where appropriate) prior to the administration of chemical restraint. Again, this is longstanding [6][7][8]. Notably, there is both anecdotal and research evidence that family members who are designated or default decision makers are neither consulted in regard to consent for chemical restraint [8], nor informed about major side effects including mortality risk, while often subject to pressure by Residential Aged Care Facilities (RACFs) to accede to such restraint [8,9] for fear of the resident with Changed Behaviours losing tenure in the facility.…”

Section: Introductionmentioning

confidence: 99%

Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity

Jessop

Peisah

2021

IJERPH

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The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia’s aged care system with a human rights approach.

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Australia's problem with obtaining consent for psychotropic use in older people

Cited by 5 publications

References 7 publications

Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services

Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity

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