industry & reform
Reducing sedative use
Exploring the RedUSe
intervention in aged care.
By Juanita Westbury
F
red was a resident with Alzheimer’s
disease living at one of our aged
care homes. He was a quiet man.
In fact, Fred had not spoken for years.
Like many people with dementia, he
became agitated and upset, particularly
around evening meals. He would refuse
to eat at certain times. Two years ago,
Fred was prescribed a small dose of
risperidone, an antipsychotic, to help
him settle.
After review, Fred was slowly taken off
his risperidone. Soon after, he mumbled
something after an evening meal. The
carer, absolutely astonished to hear him
talk, asked him to speak up.
“I hate soup … pumpkin soup.”
The carer quickly rung Fred’s family to
tell them he had spoken. They confirmed
he hated pumpkin soup with a passion.
Staff recalled that Fred became more
agitated at meals where this soup, the
cook’s speciality, was served. Being forced
to eat food he disliked was probably
contributing to his agitation. Taking a heavy
sedating drug, along with his dementia,
made it difficult for him to tell anyone.
The home pledged to never serve Fred
pumpkin soup again.
We frequently heard stories like this
when our intervention, RedUSe (Reducing
Use of Sedatives), was delivered to 150
14 agedcareinsite.com.au
aged care homes across Australia from
2014 to 2016. 1 Few were as dramatic
as Fred’s, but we often heard staff say
that when residents came off sedating
medication they became more engaged
and less confused. For many, reducing
the drugs made little difference to their
agitation level or other behaviours. Care
staff also told us they felt a sense of
achievement when they successfully
managed an agitated or anxious resident
without resorting to medication.
It is important to acknowledge that
some residents do require psychiatric
medication with sedating properties
(i.e. antipsychotics, benzodiazepines,
sedating antidepressants) if they have
mental illness such as schizophrenia,
bipolar disorder, severe anxiety states
and major depression. Further, some
people with dementia experience very
high levels of distress, hallucinations and/
or pose a risk of harm to themselves or
others. Prescribing antipsychotics to
these residents is justified provided their
effectiveness and adverse effects are
closely monitored and the lowest effective
dose is taken for a time-limited period
(usually three months). 2
However, when these medications are
given to older people with less serious
symptoms such as calling out, agitation
and wandering, the risks associated with
use often outweigh any benefit they
may offer. To give an example, about
one in five residents with dementia
experiencing agitation will benefit from
taking antipsychotics, yet taking these
medications increases the risk of stroke,
pneumonia, death from all causes, cardiac
problems, falls, tremor and confusion. 2
My own qualitative research, and that
of researchers overseas, has found that
care staff will often request psychotropic
medication from prescribers with the
aim of ‘providing comfort’ or ‘to calm’
residents. 3 Most staff don’t want to ‘dope
residents up’ for their own convenience.
Many staff and health practitioners also
have a strong belief in medication, trusting
that these drugs are much more effective
than the evidence suggests. When we
gave staff a psychiatric drug knowledge
quiz, we found that most care staff and
health practitioners were unaware of
their adverse effects. 4 Few could name a
guideline they referred to when prescribing
or administering these medications. There
is also marked resistance to take residents
off sedating medication for fear that
behaviours will escalate. Yet, withdrawal
studies suggest that most people with less
severe symptoms can be taken off these
medications successfully with minimal
impact on behaviour. 5
What does the RedUSe intervention
involve? It’s a program lasting six months
involving awareness raising, education
and sedative review. To raise awareness
of sedative medication use, we audited
each home and then compared their use
to others. One large Queensland home
assured me they didn’t have a problem,
only to find that over a third of residents
were taking antipsychotics. If you don’t
measure or compare use, it’s difficult to
assess if use is too high.
After, the audit results are provided to
staff, along with education on sedative
use by trained pharmacists. These
sessions aimed to promote discussion
by asking if these drugs improved quality
of life, provoking some very spirited
debates. Finally, a structured review
process was conducted where a nurse,
pharmacist and GP reviewed all residents
at the home taking sedatives. 1
Over the past few months, when bad
news stories about aged care prevailed, we
found that most aged care staff wanted to