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CPD ACTIVITY
73
RET AIL PHARMA C Y • MA Y 2020
within the residential aged care
system, including inadequate staffing
and training, and stressful workloads,
prescribers can find themselves
under pressure from facility staff to
prescribe a medicine to deal with
unwanted behaviours, rather than
rely on behavioural interventions.
4,12
Australian practice guidelines state
that a patient or their representative
should provide informed consent
before the use of treatment, and the
final decision regarding the use of
a medication to treat behavioural
disturbances should be made by the
patient or their representative, not the
treating clinician.
14
As well as adhering to relevant
legislation, pharmacists should ensure
that psychotropic drugs are being used
safely and appropriately, in line with the
principles detailed in the ‘Code of Ethics
for Pharmacists’ (Pharmaceutical Society
of Australia, 2017).
What medicines are used?
In aged care, a number of different
classes of medicine may be used as
chemical restraint. The medicines used
most frequently for the purpose include
antipsychotics and benzodiazepines.
4
Baseline data collected in the Australian
RedUSe study showed that around 22
per cent of residents were prescribed
an antipsychotic, and around 22 per
cent prescribed a benzodiazepine.
16
Research suggests that only 10 per
cent of psychotropic drugs used in
nursing home residents with dementia
were considered to be prescribed
appropriately. Specific aspects of
inappropriate prescribing were found
to be the indication, evaluation of
effect/adverse effects, and duration
of therapy.
17
It’s generally accepted that the effect
of medicines to control unwanted
behaviour is only modest, and this
should be balanced with the known
risks such as serious adverse effects.
6, 18
Refer to Table 1 for the serious adverse
effects associated with the two most
commonly used classes of psychotropic
for chemical restraint.
Not all unwanted behaviours
have evidence to support the use of
medicines to modify that behaviour.
Little evidence currently suggests
that antipsychotics are effective for
certain behaviours, such as wandering,
in patients with dementia. For the
14
treatment of verbally disruptive
behaviours, such as calling out or
screaming, guidelines recommend the
use of therapeutic recreation unless
pharmacological agents are indicated
(ie, if psychosis is present). In practice,
6
chemical restraint in the form of sedation
may be used to such an extent that the
person is no longer able to demonstrate
the behaviour that cannot be
successfully modified, eg, wandering.
4
Antipsychotics
Evidence supports the use of
haloperidol, risperidone and olanzapine
for the treatment of aggression
associated with dementia.
18,21
While haloperidol was associated
with improvements in aggression,
it didn’t improve other aspects of
agitation. When treating aggression,
21
both risperidone and olanzapine
demonstrated significant improvement
compared with placebo, and risperidone
also significantly improved psychosis.
However, both are associated with a
significantly higher incidence of adverse
events. A 2006 Cochrane Review
18
found that risperidone is associated
with an almost fourfold increase in
the risk of cerebrovascular adverse
events, may double the incidence of
extrapyramidal symptoms at doses of
1mg to 2mg, and is associated with dose
dependent increases in somnolence,
fever, oedema, number of upper
respiratory tract infections, and urinary
tract infections. Antipsychotics are also
18
known to increase the mortality risk in
older adults. Mortality risk increases with
the number of psychotropic medicines
taken concomitantly.
22
Risperidone is the only antipsychotic
currently listed on the PBS for the
treatment of behavioural disturbances
in patients with the Alzheimer type of
dementia who are displaying psychotic
symptoms and aggression, with strict
clinical criteria including restricting use
to 12 weeks of therapy and review.
23
Antipsychotics are not appropriate in all
types of dementia. For instance, the use
of antipsychotics in Lewy body dementia
can lead to reduced motor and cognitive
function, and increased agitation, and
can increase unwanted behaviours in
some patients.
19
An initial dose of 0.25mg of risperidone
twice daily may be trialled. The dose can
be increased by 0.25mg every two or
more days if necessary. The maximum
daily dose is 2mg. If olanzapine is
24
to be initiated, an appropriate starting
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Benzodiazepines
Antipsychotics
Confusion
Confusion
Falls
Falls
Ataxia
Extrapyramidal symptoms
Respiratory depression
Orthostatic hypotension
Memory impairment
Anticholinergic effects
Drowsiness
Drowsiness
Paradoxical excitation
Stroke
Aggression and hostility
QT prolongation
Pneumonia
Pneumonia
Death
Death
Table 1.
Adverse effects associated with commonly prescribed agents used for chemical restraint in the elderly.
18-20