Restrictive practice is an intervention or practice that restricts the rights or freedom of movement of the person. There are five restrictive practices in aged care – chemical restraint, environmental restraint, mechanical restraint, physical restraint and seclusion.
As per the new legislation introduced on 1 July 2021, chemical restraint is only to be used as a last resort. It should be implemented for the least amount of time possible and recorded, monitored and reviewed by providers. The amendments introduced in the new legislation are aimed at clarifying and strengthening the responsibilities of approved providers of residential aged care.
Chemical restraint involves medication use mainly to control a patient’s behaviour. It was a term not accepted by providers in aged care. Many accepted the high rates of psychotropic and benzodiazepine use in aged care, but justified their use to treat residents with dementia, anxiety or insomnia.
Medications classified as chemical restraint include antipsychotics, benzodiazepines, sedating antidepressants, anticonvulsants, opioids and Z drugs (zolpidem, zopiclone).
These medications are exempt from being classified as chemical restraint when used in:
- A diagnosed mental disorder;
- A physical illness;
- A physical condition; or
- End of life care
Regular or when needed use prescribing has no bearing on a medication being considered as chemical restraint.
The legislation details what residential aged care providers must do whenever chemical restraint is considered and used, including in an emergency.
Chemical restraint can only be used if the prescriber has assessed the person as being at risk of harming themselves or others. The assessment, decision to use restraint, and behaviours requiring restraint should be documented in the consumer’s care and services plan. Informed consent by the resident or, if they lack capacity, a substitute decision-maker, is necessary before administering chemical restraint. In an emergency situation, the resident or substitute decision-maker must be informed and reasons for use documented as soon as practical after administering chemical restraint.
Nearly 60% of aged care residents have at least one mental health disorder (46% depression, 15% phobia/anxiety and 10% psychosis). This does not mean that all their psychotropic use is exempt from being chemical restraint. When a medication is used to address behaviour (e.g. agitation, calling out, wandering, disinhibition, aggression, intrusive behaviour), then it is classified as a chemical restraint (unless it is used in end of life care or to enable medical or dental treatment). When used for psychosis associated with a mental disorder, then it is not a chemical restraint. However, antipsychotic use in dementia should be reserved for severe symptoms that have not responded to non-pharmacological strategies, e.g. the resident is extremely distressed and their safety or that of others is at risk. Psychotropic medications have a modest effect on many behavioural and psychological symptoms of dementia, but it needs to be weighed up against the significant adverse effects they can cause, e.g. increased risk of death, stroke, falls and movement disorders.
Prescribing a hypnotic for short term treatment (up to two weeks) after psychological and behavioural therapies have been trialled is not chemical restraint. But if it is used to stop a resident from disturbing others or fitting in with the aged care schedule, then it is chemical restraint. When a resident needs a benzodiazepine to allow them to comfortably undergo a medical or dental procedure, then its use is not classified as chemical restraint. In this instance, it is to enable treatment of a physical illness or condition.
After administering chemical restraint, monitoring for signs of distress, adverse effects, and changes to the person’s ability to engage in activities of daily living is necessary. Monitoring and reviewing ensure that chemical restraint is still needed and is the least restrictive form. It assesses effectiveness and, where possible, the use of alternative strategies.
In summary, aged care homes must assess residents to identify causes for behaviours and develop individualised behaviour support plans. They must consider whether the risk of harm can be managed using non-pharmacological strategies and use these options to their best effect before chemical restraint is used.
- Australian Government. Aged care and other Legislation Amendment (Royal Commission Response No. 1) Bill 2021. Federal Register of Legislation; 2021.
- Australian Government. Regulatory bulletin: Regulation of restrictive practices and the role of the senior practitioner, restrictive practices. Aged Care Quality and Safety Commission; 2022.
- International Psychogeriatric Association (IPA). The IPA Complete Guides to the Behavioral and Psychological Symptoms of Dementia: Specialists Guide. IPA: Milwaukee; 2015.
- Royal Australian and New Zealand College of Psychiatrists. Antipsychotic medications as a treatment of behavioural and psychological symptoms of dementia (Professional Practice Guideline 10). Melbourne: RANZCP; 2016.
- Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice. Part B – Benzodiazepines. RACGP; 2015.