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Avoiding medication when residents become aggressive


The aged care inquiry has been told that up to 80 per cent of dementia residents are being prescribed psychotropic drugs, particularly when managing residents with aggressive or agitated symptoms. There are other solution-focused ways to try and overcome a resident’s aggression or agitation, Tamar Krebs writes.

Tamar Krebs

Medication is not a substitute for quality care.

Medication is not a substitute for quality care. Whilst, many care facilities handle the issue of medication responsibly and with sensitivity, the Royal Commission has highlighted some examples of opioid and schedule-one medications being used too often and too freely on some dementia residents, and with damaging effects.

Each individual has varied set of needs.

It may be that medication and sedation have been seen as an alternative to behavioural therapy, or an easier option for demanding residents when staff and resources are stretched to capacity. However, there are alternatives to medication, that should be more widely adopted, beginning with a sensitive and individualised approach to each resident.

Aggressive outbursts usually signify an unmet need

There is a significant life beyond the diagnosis of dementia. Aggressive outbursts, when they do occur, usually signify a particular unmet need in the individual such as pain, frustration, tiredness or any one of a myriad of other disease side-effects. Agitation and anxiety only constitute a small part of the resident’s experience, without defining them.

Residents may experience different symptoms at different times of the day

Residents may experience different symptoms of the disease at different times of the day, and just like one wouldn’t prescribe Panadol at 8am for a headache that usually arrives at 3pm, there is little need to medicate or sedate dementia residents without a clear and specific knowledge of their individual disease patterns and symptoms.

Residents may be frustrated

Aggressive or agitated outbursts may simply be an expression of frustration in the resident due to an imperfect approach to their treatment. Residents who have been high-functioning, active and interested in say local history will gain little pleasure or therapeutic benefit from a treatment that includes long periods of inertia, bingo games or origami workshops. Once their treatment is adjusted to include activities and therapies that appeal to their genuine needs and interests, the so-called aggression or agitation often disappears.

Carers need to minimise or eliminate known triggers

In addition to this, it can be beneficial for therapies to minimise or eliminate triggers known to prompt outbursts. Triggers can be either internal or external, such as loud noises, frightening experiences or new environments and even inexperienced staff.

Aggression is an opportunity to meet a specific need

When aggression does occur, it often represents an opportunity for us to meet a resident’s specific need in a better, more tailored way, without medication.

Learn about the resident and what they enjoy

We remain curious about the residents, their families and their communities and learn as much as we can about who they are, what they enjoy and what they see as their purpose. We deliver as much of these into their routines before turning to medication as an additional therapy.

When this medication is introduced adopt a “start low, go slow” approach

Medication is a valuable tool when used properly. When used carefully and in context, they are known to diminish dementia symptoms.

When this medication is introduced adopt a “start low, go slow” approach with the goal of reducing the impact of the known triggers and to reduce the severity of the anxiety and aggressive episodes.

Tamar Krebs is the Founder and Co-CEO of Group Homes Australia (GHA).

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5 Responses to Avoiding medication when residents become aggressive

  1. Robyn Carter March 24, 2019 at 5:11 pm #

    OK- are you the commission gurus going to come and work on the floor where we have resident who physically assault our staff and other residents on an on going basis – which is against all WHS laws of every state where we are responsible for providing a SAFE WORK ENVIRONMENT for all our staff and others including other residents and visitors – Answer- how are we to provide a safe workplace in aged care where staff are reportedly punched and injured
    Would you come to work every day knowing you were going to be bashed and injured by aggressive resident in aged care – this is a WHS issue and it is now considered Domestic Violence as per law against other residents and workers .
    Now tell me the solution – and do you face this in your workplace every day ?

  2. Tony Schumacher-Jones March 29, 2019 at 2:39 pm #

    Hi Robyn, I hear what you are saying.

    I think anti-psychotic meds have a role to play. Currently it seems that we are focusing on the one resident who is particularly aggressive and their welfare and their ‘right’ if that is the word, to be free of anti-psychotics or free of any adverse side affects of anti-psychotics such as sedation and/or drowsiness.

    As a prima facie position, well that’s fine. But that aggression can be directed at other frail residents and as well, care staff who surely have a right to a violence free work place.

    Sure, we do not want to use so much medication that a person is so sedated that they cannot move, but when it comes to protecting other frail residents or staff then I think these two variables need to be taken into the equation.

    Personally I would err on the side of sedating one person to protect many more from harm. Its a difficult balancing act, but the safety and the good of the many ought to be put before the best interests of the one.

    And I would have hoped that the author of the piece replied to you.

    Cheers

  3. Louise Galea March 30, 2019 at 10:42 am #

    I agree totally with the previous two comments. What the author states is spending time to learn why. All great in theory, however look at the staff shortages, the ratio of staff to residents is obscene. A Diversional Therapist/ lifestyle team would be able to help but their ratio to the amount of residents is even worse than the ratio of PCA’s. Tell me how 1 lifestyle person to 80 people or more can be across everyone. Nursing staff are too busy OR too junior to understand how to deal with behaviours. Dementia training is extremely poor in majority of homes. Watch a 30 minute training video on what is dementia, that’s it! Every home should have a professionally trained dementia expert on their books but that is not reality in the industry. 99% of people who are working on the floor would love the time to spend with people and support and assist however it is all about working faster, it does not include quality of care. Families must co care.

  4. Dave April 2, 2019 at 7:31 pm #

    This wont to be popular, but here we go

    – We’re all tired of expert non-clinicians regurgitating the same old generic ‘advice’. These are usually the same people who preside over staff cuts and the removal of RNs

    – If someone is that aggressive on a daily basis, what’s he doing in your facility? He requires a complete review by experts in an acute health care setting. Sounds like an inappropriate admission…Is occupancy your main consideration?

    – Anti-psychotics have their place, but most are incorrectly prescribed and administered for the wrong reasons. ‘Sedating one person to protect many more…” is just one of those wrong reasons.

    – Read the literature. These drugs don’t what you’re hoping they’ll do. (unless you’re hoping for falls, strokes and high mortality rates). Even when correctly prescribed, their efficacy is modest at best

    – The majority of adverse behavioral incidents in residential care are our fault. Unskilled, unsupported, unsupervised and task-oriented carers blissfully unaware of residents’ personal history or person-specific behaviour management techniques. Grabbing and fighting with residents (have a look at all the bruises on their wrists and backs of their hands) just so they can complete that critically important shower list.(or the afternoon staff will complain.)

    – A severe lack of specialty facilities with the staff, skill and building design to manage the particularly challenging people. Not a crowded locked dementia unit staffed by unskilled migrant workers with limited English.

    – Too many residents, too few skilled staff. Raise your concerns with external authorities…don’t just accept this as normal and hope it can be fixed with more drugs

    Let’s be honest, most residential facilities are operating out of their league. Aged care needs more specialty units and less 5 star hotels.

  5. Angela April 3, 2019 at 8:01 am #

    “There is little need to medicate or sedate dementia residents.” Does anyone else see a problem with this sentence? Language and our view of the people we care for is so important. The term ” dementia resident” says so very much about what is wrong with the care being given to people. They are people first. People LIVING WITH dementia Using language like “dementia resident” is no different to saying “demented resident”. The term “dementia resident” is a label and it dehumanises the person who is living with dementia. We still have such a long way to go. Sigh!

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