The effective management of patients with challenging behaviours should include a personalised assessment and care plan.5
On admission to an RACF, a comprehensive medical assessment (CMA) is can be performed on all new patients and it is recommended to do it within six weeks. It is an opportunity to include an assessment of the risk of challenging behaviours and a management plan. The BPSD management plan will include information about restrictive practices, especially if the patient has a history of, or potential for, serious harm or potential serious harm to the patient themselves, other residents in the RACF and/or RACF staff. The management of BPSD symptoms requires a multidisciplinary team approach and good communication between the care team and patient/their representatives (especially a legally appointed person with medical power of attorney). A case conference may be a suitable mechanism to facilitate those conversations. Predicting the need for management of challenging behaviours will allow for a pre-emptive case conference and allow the RACF staff to prepare.
The first-line management should include a person-centred, multidisciplinary management plan of non-pharmacological approaches. The multidisciplinary team may include GPs, nurses, RACF staff, carers, families, other specialist medical practitioners (eg geriatrician, psychogeriatrician), pharmacists and allied health professionals.
Together, the multidisciplinary team should first seek to manage the underlying cause of the behaviour in order to minimise or avoid the use of pharmacotherapy for BPSD. Importantly, this will include the early identification and adoption of preventive and early intervention measures.
Non-pharmacological management plans must be person-centred, but may include:6
- reduce environmental noise and lighting
- reduce risk of confusion
- improve lighting
- provide appropriate bedding
- engage and interact with familiar staff
- conduct sensory stimulating activities
- provide companionship
- provide sensory aids
- increased supervision
- appropriate staffing and training
The prescription of Pharmaceutical Benefits Scheme (PBS) approved psychotropic drug (ie risperidone), can only be prescribed after non-pharmacological management have been attempted and failed.9
The use of pharmacological management should only be considered after attempts of non-pharmacological management have failed, and co-administered with other non-pharmacological management.10 While the use of antipsychotics can assist with patients who pose a serious risk of harm to themselves, other residents or RACF staff, it can still be a stressful process for all individuals involved.
Medical practitioners need to be cognisant that the use of antipsychotics must be:
- for the benefit of the patient.
- to prevent harm or potential serious harm to the patient, other residents and/or RACF staff
- a last resort in a setting requiring an urgent response
- the least restrictive option
- carefully monitored, reviewed and clinically observed
- previously documented in the patient’s management plan, if necessary
- clear and unambiguous instructions on when the pharmacotherapy for BPSD can be used
- identify the precipitating and exacerbating factors
- suggest graded series of responses
- documented in the patient’s notes
- discussed and reviewed with the patient
- subject to regular review (eg three monthly)
- accompanied by the appropriate consent
- appropriately communicated to the patient and their representatives (especially a legally appointed person with medical power of attorney)
- accompanied by a careful assessment of the patient’s safety.
The misuse of psychotropic medicines may significantly affect the individual patient, and can adversely affect:11,12,13,14,15
- sedation, gait disturbances and increased risk of falls and fractures
- urinary tract infections
- urinary and faecal incontinence
- cognitive impairment and confusion
- risk for extrapyramidal side effects (eg restlessness, agitation)
- risk of respiratory complications (eg pneumonia), stroke and heart rhythm abnormalities, cerebrovascular events (eg stroke)
- risk of death.
Available literature has also found that the long-term use of benzodiazepines can lead to long-term cognitive impairment and increased risk of dementia.16,17
Once it has been established that antipsychotics are necessary for the comfort, dignity and safety of the patient and non-pharmacological management has failed, it is appropriate to initiate them.
- Assess the patient for contraindications for the medication.
- Communicate with the patient’s legally appointed person with medical power of attorney regarding the decision and obtain their consent.
- Communicate with the RACF staff regarding the need for, the use of and observable side effects of the prescribed antipsychotic, and document the above.
- Prescribe the medication at a low dose.
- Review the patient within a week and regularly thereafter as required.
- Set a reminder and arrange to review the patient in 12 weeks with the plan to wean and cease the medication if possible.
Failure to obtain a patient or their legally appointed person with medical power of attorney’s lawful consent before the administration of pharmacotherapy for BPSD may infringe on the patient’s legal rights. It is therefore important to clearly document the following in the patient’s medical record:
- discussion of risks and failure of non-pharmacological strategies
- who provided consent.
Decision making regarding care and treatment of those in RACFs must operate within state and territory legal frameworks. State and territory legislation provides guidance on when a patient is unable to provide consent to receiving medical treatment, and circumstances under which a substitute decision maker is able to assume responsibility.
The various legislation allows patients who have capacity to make arrangements for a substitute decision maker if and when they do not have the capacity to provide consent.18 In New South Wales, if an individual is unable to provide consent to a medical practitioner, they must seek consent from an authorised individual to provide consent.19
It is therefore imperative for RACFs and medical practitioners to be aware of the legislation governing consent if it is determined to be necessary to use a pharmacotherapy for BPSD on a patient. However, in the acute clinical setting, this may be impractical and may lead to further potential harm to the patient, other residents in the RACF and RACF staff.
In situations where the use of pharmacotherapy for BPSD may be necessary, the patient is most likely unable to provide informed consent. Legislation and common law then indicates that informed consent must be obtained from a substitute decision maker; however, in reality, this can often be difficult to actualise.
It must be highlighted that in acute situations, where there is an urgent need to act quickly to safeguard the patient or others, restrictive practices may necessary and required. In this case, the judgement of the GP on starting the medication is appropriate; however, obtaining consent as soon as practically possible is imperative. These issues may be addressed by identifying the potential situation with the patient and family, and obtaining the necessary consent to act before the acute situation occurs.
Reviewing and weaning
As highlighted by the NSW Ministry of Health, ‘[s]ince the natural history of BPSD is variable (symptoms may be intermittent and may settle spontaneously), it is recommended that the use of such agents is time limited and reviewed for their potential discontinuation at least three-monthly’.20
Most practices have a process set up to set reminders for patients and GPs, and the GP can use this process to remember to review the patient after 12 weeks or less. Alternatively, another strategy would be to prescribe for a defined period of time on the medication chart.
Extrapolating from the adverse effect profile, Table 1 provides recommendations for assessment at the three-month antipsychotic review.
Consider the following at the three-month antipsychotic review
Taking a history and documenting the following points is part of the assessment:
- When was the last attempt at weaning?
- Outcome of previous weaning attempt.
- Pain, bowel actions and sleep assessment.
- Behaviour assessment using appropriate tools (eg Neuropsychiatric Inventory).
- Assess the patient’s alcohol use and smoking status, as these may affect the use of psychotropic medications.
On examination, document the following.
- neurological exam – consider parkinsonism, gait disturbance, tremor.
- pulse rate and rhythm.
Consider the following Investigations:
- full blood count, total cholesterol, triglycerides, high-density lipoprotein, and blood glucose levels or glycated haemoglobin (HbA1c) every three to six months, if indicated
- electrocardiography (ECG), if possible.
The actions following on from the assessment would be to:
- plan to wean and cease the medication
- continue with the medication – It will need to be clearly noted as to the reasons and indication for continuing
- consider that continuing the medication would follow the same advice above regarding initiating the medication
- conduct a case conference to discuss the plan for the following three months
- consider calling Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Team (SBRT) if these behaviours persists.